Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children. ⋯ The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.
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Case Reports
Acute Coronary Ischemia Identified by EMS Providers in a Standing Middle-aged Male with Atypical Symptoms.
Acute coronary syndrome and myocardial infarction have been described to present with atypical symptoms in certain subsets of patients. However, these subsets commonly do not include middle-aged males with a paucity of underlying medical conditions. ⋯ Further, electrocardiographic changes consistent with acute ischemia could only be demonstrated with the patient in a standing position, prior to the development of an occurrence of ventricular tachycardia, which degenerated into ventricular fibrillation. To our knowledge, this is a very rare case of electrocardiographic changes consistent with occult, acute cardiac ischemia with a proven coronary artery lesion seen initially only with the patient in a standing position.
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Comparative Study
Symptoms of Myocardial Infarction: Concordance between Paramedic and Hospital Records.
To further reduce time to definitive therapy for acute myocardial infarction (MI) patients, the focus of research needs to be on better understanding prehospital delay in recognition and response to symptoms. Paramedic clinical records can serve as a convenient source of data for such studies, but their accuracy needs to be established. ⋯ Our study demonstrated that documentation of the common symptoms of MI and symptom-onset time was similar between the paramedic and hospital records, justifying the use of paramedic PCRs as a source of data for research in prehospital MI patient delay. Further research is required to investigate why symptom-onset time was not routinely documented for all patients with chest pain.
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Observational Study
Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients.
Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (i.v.) resuscitation and examine the association of elevation on in-hospital death. ⋯ Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.
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Although pediatric-specific objectives for the initial education of prehospital providers have been established, uniform implementation of these objectives and guidelines for hours of required pediatric continuing education (CE) for prehospital providers have not been established. ⋯ Modifying statewide policies on prehospital education and increasing hands-on training may overcome identified barriers.