Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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A paramedic may be unprepared to practice alone or with an inexperienced partner immediately following completion of training. Emergency medical services systems have not generally set standards to ensure that a newly-licensed paramedic is competent to practice alone. ⋯ This paper summarizes mentoring requirements for other clinical professions and reviews studies from the out-of-hospital and hospital literature that demonstrate a positive correlation between experience and outcome and/or competence. The author recommends specific benchmarking and supervision by a training officer or an experienced paramedic to ensure competence in new and inexperienced paramedics.
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Approximately 1,000 people in the United States suffer cardiac arrest each day, most often as a complication of acute myocardial infarction (AMI) with accompanying ventricular fibrillation or unstable ventricular tachycardia. Increasing the number of patients who survive cardiac arrest and minimizing the clinical sequelae associated with cardiac arrest in those who do survive are the objectives of emergency medical personnel. In 1990, the American Heart Association (AHA) suggested the chain of survival concept, with four links--early access, cardiopulmonary resuscitation (CPR), defibrillation, and advanced care--as the way to approach cardiac arrest. ⋯ This paper addresses a number of the issues associated with each of the links of the chain of survival, the evidence that exists, and what should be done to achieve the clinical evidence needed for true clinical significance. Also included in this paper are the consensus statements developed from small discussion groups held after the main presentation. These comments provide another perspective to the problems and to possible approaches to deal with them.
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End-tidal carbon dioxide (ETCO2) monitoring is an exciting technology and has the potential to become a very useful tool in the prehospital setting. It can be useful in verifying endotracheal tube position and during cardiopulmonary resuscitation in the field. ⋯ The new American Heart Association guidelines require secondary confirmation of proper tube placement in all patients by exhaled CO2 immediately after intubation and during transport. This article covers the terminology, the basic physiology, the technology (both colorimetric detectors and infrared capnometers), and the clinical applications of ETCO2 monitoring with special reference to the pediatric patient.
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Airway management and optimal ventilation are crucial aspects of managing out-of-hospital medical emergencies. The goals in these situations are controlled ventilation and optimized inspiratory time, expiratory time, and airflow. Numerous techniques and devices are available to deliver oxygen-enriched air to patients during resuscitation. ⋯ These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Furthermore, all patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. As with any other skill, ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review.
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Awareness of the health and financial repercussions of unnecessary immobilization has made cervical spinal immobilization controversial in out-of-hospital care. Clinical criteria for clearance of the cervical spine in the hospital based on mechanism of injury have been supported by many trauma centers. However, implementation of clinical criteria for cervical spinal clearance in out-of-hospital settings is not as well validated by multicenter studies or accepted by many emergency departments. This consensus group recommends that clinical criteria to determine "low-risk" patients be available for use by emergency medical services providers in out-of-hospital settings; however, training, audits, quality management, integration into the medical community, and extent of program implementation should be decided based on individual emergency medical services systems.