Hypothesis: Do paramedics influence the outcome of out of hospital cardiac arrests in a rural setting?

Methods: Retrospective analysis of cardio-respiratory arrests of ALS-EMS system in rural Southeastern Alaska for 9 years. There were two patient groups treated by EMT-III or paramedics. EMT-III vs. paramedics differ in training/experience but not technical skills. Statistical analyses were done by chi square.

Results: Thirty-seven patients (52%) were treated by paramedics, thirty-four (48%) by EMT-III. Demographics/CPR variables for the groups were not significantly different. Comparing paramedics vs. EMT-III: successful ET placement (87% vs. 62%, p <0.02), successful IV placement (87% vs. 62%, p <0.02), return of spontaneous circulation (ROSC) 46% (17/37 pts.) vs. 18% (6/34 pts.) (p = 0.01), ICU admission 38% (14/37) vs. 15% (5/34) (p = 0.03), hospital discharge 20% (7/35) vs. 9% (3/34) (p = NS). There was no correlation between successful ET placement or IV insertion and outcome.

The fall of the Berlin wall was a symbol of the failure of two systems to exist totally independent of each other. It also rendered obsolete the grand scenarios necessitated by the Cold War for dealing with a nuclear bombing attack. We hope and expect that these particular scenarios based on the premise of hostility between the world powers of the East and West never will need to be considered again. However, both sides gained a tremendous amount of experience in how nuclear and other weapons and industries operate, their health and environmental effects, and the extreme danger of these weapons. In the present time of peace among the world powers, it is important to develop disaster response scenarios that will be useful world-wide. We must contribute our collective wisdom and experience through working together as a world community. The recent cooperation between the United States and Russia in joint space program efforts is an example of the progress that can be made through close collaboration between countries that formerly were adversaries.

An estimated 110 million land mines scattered in 64 countries continue to terrorize people and destroy human lives long after wars and fighting have ceased. Despite efforts to clear these devices, their numbers continue to increase and their presence, constitutes a substantial threat to public health in the affected countries. Direct consequences include both the physical and emotional injuries from the impact, flying debris, and structural collapse associated with their detonation. Indirect consequences include increases in the incidence of waterborne diseases, diarrhea, malnutrition, infectious diseases, and spread of the human immunodeficiency virus associated with the increased use of blood. Those at highest risk of these latter consequences are mostly the disadvantaged poor, especially children. Psychiatric disorders, such as post-traumatic stress disorder, occur in those not directly injured as well as those physically wounded by the explosion.

Besides efforts to ban production, stockpiling and export of land mines, a comprehensive and integrated health program aimed at the prevention, treatment, and rehabilitation of those injured directly or indirectly by land mines is needed urgently. Strategies should include mine-awareness programs, enhanced transport of those directly injured, training the villagers in first aid, augmenting the capacity and quality of treatment facilities, improving the psychological support and treatment capabilities, development of rehabilitation programs, and the institution and enhancement of public-health programs directed at the indirect consequences associated with the presence of land mines.

Land mines constitute a major public-health problem in the world that must be addressed.

Purpose: To determine how often house fires occur at addresses visited previously for emergency medical services (EMS) and were these visits missed opportunities for a point-of-contact fire safety intervention.

Method: Retrospective analysis of all Fire Department (FD) responses during 1994. Data studied with descriptive statistics: reason for response, property type, dollar loss estimate, injuries, fatalities, fire cause, smoke detector operation.

Results: The FD responded to 94,378 requests for service at 43,556 addresses. 27,406 addresses generated one response. However, 16,150 addresses had multiple requests, receiving 66,972 responses. For the multiple requests, 1,162 addresses had a fire condition of which 728 addresses requested EMS prior to the fire condition. 215 were one/two-family dwelling addresses receiving 489 responses; mean 2.3 EMS responses prior to the fire condition. 182/215 (85%) of these addresses had complete data, incurring a dollar loss estimate of [US]$2,017,470, 33 injuries and 0 fatalities. The top five causes for the fire condition were children playing with smoking materials, arson, suspicious, scorched food and undetermined. 87/182 (49%) of the one/two-family dwellings had a smoke detector present. However, only 31/182 (17%) of the dwellings had an operational smoke detector.

Purpose: The use of automatic external defibrillators (AED) by emergency medical service (EMS) first responders (FR) is widely advocated based largely on reports from one metropolitan area, but widespread impact on survival remains unproven. We hypothesized that the addition of AEDs to an EMS system with short FR and prolonged paramedic response times (4 vs. 10 minutes) would improve survival from sudden cardiac death.

Methods: Prospective, controlled, crossover study (AED vs. no AED) of consecutive cardiac arrests managed by 24 FR fire companies from 1992–1995 in a city of 440,000. Patients were stratified by the Utstein criteria. Primary end-point was survival to hospital discharge among patients with bystander witnessed arrests of cardiac etiology. Power was set at 0.8 to detect a 10% difference in survival.

Results: A total of 627 patients were studied. Groups were comparable for age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and ventricular fibrillation (VF) as initial rhythm.

Critical thinking has become a buzzword, especially in medical education. The challenge is first to determine what skills compose critical thinking and what teaching techniques promote critical-thinking skills, and then to determine how to apply these techniques effectively and efficiently to a given population in the classroom.

This article begins with a working definition of critical thinking and explores the parameters and skills implied or stated in the definition. Then a teaching environment constructed around a model of critical thinking and characteristics of the audience is described. A specific teaching method, suggested by research and designed to exercise critical-thinking skills, is then applied to a specific patient problem in a continuing education class. Preliminary outcomes are presented.

The purpose of this article is to propose a productive and efficient educational method for promoting and enhancing critical-thinking skills appropriate for paramedic-level continuing education.

Hypothesis: Assessments to rule out cervical spine injury performed by emergency medical services (EMS) personnel correlate well with assessments performed by emergency department (ED) physicians. Methods: EMS providers completed a data form based on their initial assessment of all immobilized adult patients. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurological deficit; and other painful/distracting injury. Immobilization was considered to be indicated if any one of the six physical findings was present. The ED physician caring for the patient completed an identical data form based on his/her assessment. Physicians and EMS providers were blinded to each other's assessments. The amount of discordance between the physician and EMS assessments was analyzed using McNemar's Chi-Square for matched pairs.

Results: Five-hundred-seventy-three patients were included in the study. Physician and EMS assessments matched in 78.7% (n = 451) of the cases. In 13.6% (n = 78) of the cases, the EMS assessment indicated immobilization, but the physician assessment did not. In 7.7% (n = 44) of the patients, the physician assessment indicated immobilization, but the EMS assessment did not. The discordance between assessments was statistically significant (p <0.001). The presence of neck pain or tenderness accounted for the most discordance.

Prehospital 12-lead electrocardiographic (ECG) diagnostic strategies have been proven feasible and effective, provided they are designed and implemented properly. The authors of this communication have expended considerable time and effort in determining appropriate planning, implementation, and process monitoring necessary for successful implementation of a variety of prehospital diagnostic strategies. Many of these issues may not be obvious to an emergency medical services (EMS) director initiating a 12-lead ECG program. This level of attention to protocol development, education, training, inservice education, coordination of the health-care community, objective program assessment, monitoring and continuos quality improvement can serve as a model for other diagnostic EMS programs that may develop as an expanded role for EMS.