Articles: emergency-medical-services.
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Clinical Trial
Prehospital defibrillation performed by emergency medical technicians in rural communities.
Survival after out-of-hospital cardiac arrest is poor in communities served only by basic ambulance services, but conventional advanced prehospital care is not an option for most rural communities. Ambulance technicians in 18 small communities (average population, 10,400) were trained to recognize and defibrillate ventricular fibrillation. Neither endotracheal intubation nor medication was used. ⋯ In the communities where early defibrillation was available, 12 of 64 patients (19 per cent) who were found in ventricular fibrillation were resuscitated and discharged alive from the hospital; this was true of only 1 of 31 such patients (3 per cent) in the control communities, where only basic life support was available (P less than 0.05). Ten (83 per cent) of the long-term survivors received electrical shocks administered solely by the technicians. Early defibrillation by minimally trained ambulance technicians is an effective approach to emergency cardiac care in rural communities.
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The outcome in 126 consecutive patients with nontraumatic out-of-hospital cardiac arrest was analyzed to determine the effectiveness of a standard ambulance system over 22 months. Therapy was limited to basic life support (that is, administration of oxygen by mask, i.v. fluids, closed-chest massage and artificial respiration) by emergency medical technicians in a community in which less than 1% of the population had been trained in cardiopulmonary resuscitation (CPR). Analyses of patient data were performed to determine the relations between survival to hospital admission or discharge and 6 variables; response time, prior CPR, initial rhythm, acute myocardial infarction, initial blood pressure and initial pulse. ⋯ Two patient subgroups had a higher discharge rate: those with an initial rhythm of ventricular tachycardia or fibrillation (7 of 50, 14%), and those with an initial blood pressure greater than or equal to 90 mm Hg and a pulse rate of greater than 50 beats/min (3 of 6, 50%). For patients in arrest before ambulance arrival, there was no difference in outcome between those who did or those who did not receive prior CPR. Results of this study can be used as a basis for evaluating and comparing interventions directed toward stabilization of patients during the prehospital phase of cardiac arrest.
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Except for categoric grants, the federal government has divested itself of financing emergency medical services. Now the leadership for regional planning of emergency medical services must come from the state, usually from the health department. If we are to obtain improved hospital care of trauma patients, it is critical that we separate hospitals that have made a genuine commitment to the care of the multiply injured patient from hospitals that have not in order to avoid the tragedy of patients being delivered to hospitals that have inadequate resources or commitment or organization to meet the needs of such patients. ⋯ In order to be a Level I or II trauma center in that categorization format, a hospital has to show evidence of a fiscal and organizational commitment on the part of the hospital administration and staff to provide care to multiply injured patients sufficient to match the needs of that patient. The experience in Germany and in various counties of the United States that have regionalized trauma care provides the expectation that 25 percent or more of patients now dying of trauma could be saved. Professional organizations have a major role in supporting improved care for trauma patients by providing support and expertise to the EMS division of the state health department as well as developing national standards for hospital care of injured persons, equipment lists for ambulances, and training standards, as has been done by the American College of Surgeons Committee on Trauma.
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Comparative Study
A survey of prehospital care paramedic/physician communication for Multnomah County (Portland), Oregon.
All field paramedic/patient encounters requiring advanced life support management in Multnomah County, Oregon, required radio/telephone communications with the emergency department physicians of the county's single medical resource hospital for a period of 6 months. A survey of these communications (compliance estimated to be 75% to 80%) demonstrated that paramedics established contact during management or transport in one-half of instances and after transport in the remainder. Consultation was estimated to be helpful in 12% to 17% of cases and of critical importance rarely. Additional benefits were seen in hospital notification, education, and as an adjunct to the medical record; and the concept of a single centralized resource hospital was established in this community.