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Prehospital pediatric trauma care is an important part of the EMS system. Review of 458 pediatric ALS trauma responses over two years treated in an urban, tiered ALS system revealed a male predominance. Violence (gunshot, stab, or assault) accounted for 46% of injuries, followed by vehicular accidents (occupant or pedestrian), with 35%. Important ALS resuscitation interventions were commonly performed en route, with a high degree of success (IVs = 93%, intubation = 79%), and did not greatly prolong field times (9 min BLS vs 11.7 min ALS). ALS procedure success rates and field times reported here are lower than previously described. Benchmark standards for the prehospital care of pediatric trauma are proposed.
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PMID:The prehospital treatment of pediatric trauma. 160 98

Career and treatment attitudes related to potential human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) exposure are reported based on a survey of 1,228 Maryland career and volunteer prehospital care providers trained to provide basic (BLS) and advanced (ALS) life support. Sixty-five percent stated potential exposure to HIV/AIDS was a major occupational stressor. Ninety-two percent stated they would treat HIV/AIDS patients if protected. Given a choice, 38% would avoid providing treatment to HIV/AIDS patients. Eighteen percent considered resigning from emergency medical services (EMS) work. An attitudinal scale (AIDSTRESS) was developed to evaluate overall treatment and career reactions. Respondents with significantly higher (more negative reactions) AIDSTRESS scores were: BLS providers, men, paid providers, personnel with more than 3 years of field experience, those working in urban areas, personnel with no formal education beyond high school, and those who stated that their HIV/AIDS training was inadequate. Implications of the findings for quality of care, career decision making, and inservice education are discussed.
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PMID:Treatment and career attitudes of prehospital care providers associated with potential exposure to HIV/AIDS. 199 37

Rural unintentional injury (UI) death rates are higher than rates for urban regions. Our trauma center serves 49 rural Appalachian (AP) counties in a 120-county rural state. We investigated the impact of prehospital and hospital resources on UI death rates in our referral area. Age-adjusted and average age- and sex-specific UI death rates from 1979-1985 were compared among 49 rural AP counties, the 71 non-Appalachian (NAP) counties, and the United States. Counties were grouped for comparisons by level of prehospital care (Advanced Life Support [ALS] vs. Basic Life Support [BLS]) and by presence (H) or absence (NH) of a hospital. Death rates were calculated using data from the 1980 population census, the National Center for Health Statistics (NCHS), and state vital statistics. Within AP, all 49 counties have ambulance service. Only 9/49 (18%) have ALS service and 13/49 (26%) have no hospital. Age-specific AP rates were higher than NAP and US rates in the 25-44 and 45-64 year age groups. AP death rates were highest for BLS and NH counties across all age groups. Rural UI death rates in the region remain unacceptably high. The reason(s) that AP death rates exceed the NAP rates is uncertain. ALS service and an available hospital were associated with lower death rates. We propose both educational and epidemiologic programs to better identify and define additional problems.
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PMID:Unintentional injury death rates in rural Appalachia. 225 67

After cardiac arrest (no flow) of more than approximately 5 minutes' duration, standard external cardiopulmonary resuscitation (CPR) basic, advanced, and prolonged life support (BLS, ALS, PLS) do not reliably produce cerebral and coronary perfusion pressures to maintain viability and achieve stable spontaneous normotension; nor do they provide prolonged control over pressure, flow, composition, and temperature of blood. Since these capabilities are often needed to achieve conscious survival, emergency closed-chest cardiopulmonary bypass (CPB) by veno-arterial pumping via oxygenator is presented in this review as a potential addition to ALS-PLS for selected cases. In six dog studies by the Pittsburgh group (n = 221; 1982 through 1988), all 179 dogs that received CPB after prolonged cardiac arrest (no flow) or after CPR (low flow) states had restoration of stable spontaneous circulation. The use of CPB enhanced survival and neurological recovery over those achieved with CPR-ALS attempts only. With CPB and standard intensive care, it was possible to reverse normothermic ventricular fibrillation (VF) cardiac arrest (no flow) of up to 15 minutes and to achieve survival without neurologic deficit; VF of 20 minutes to achieve survival but with neurologic deficit; and VF of 30 minutes to achieve transient restoration of spontaneous circulation followed by secondary cardiac death. CPB could restore stable spontaneous circulation after ice water submersion of up to 90 minutes. Other groups' laboratory and clinical results agree with these findings in general. Clinical feasibility trials are needed to work out logistic problems and to meet clinical challenges. Future possibilities for emergency CPB require further research and development.
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PMID:Emergency cardiopulmonary bypass for resuscitation from prolonged cardiac arrest. 240 78

Time is an essential element for successful CPR. Two time factors are particularly important: the duration of complete CA and the time to advanced life support. According to a registration protocol, these time factors, together with other variables and outcome were recorded in 3083 CA cases, treated by the NICU teams of 7 major Belgian hospitals. The mean duration of complete CA is 10.3 min for CPR failure (79%); 5.3 min for initial CPR success (21%); 3.4 min for long-term CPCR success (7%). The mean time to ALS is 19.7 min for CPR failure; 14.6 min for initial CPR success: 12.7 min for long-term CPCR success. Both duration of CA and time to ALS are independently related to outcome; the mean duration of BLS is less than 10 min and not significantly related to outcome. Response time of BLS and ALS are increasingly important in their 'rapid response' failure zone (time to ALS more than 8 min, time to BLS more than 4 min). The tiered MICU system, with nurse paramedics before physicians, has equal time to ALS and comparable outcome results to the non-tiered MICU system. According to our present experience, the following time goals are proposed for Belgian EMS-MICU systems: duration of CA less or equal to 4 min (introduction time less than or equal to 1 min and response time of BLS less than or equal to 3 min) and time to ALS less than or equal to 9 min. These time goals stand, in Belgium for perfection of public training in CPR and for spreading of a higher number of MICU teams countrywide.
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PMID:Influence of time intervals on outcome of CPR. The Cerebral Resuscitation Study Group. 255 Oct 17

Several time intervals, with important influence on the outcome of CA and CPR, are determined by the local EMS-MICU characteristics: time to introduction in the EMS, response time of BLS, duration of BLS before ALS. These time factors have been studied in 2779 out-of-hospital CA cases, treated by the MICU in teams of 7 major Belgian hospitals. The analysis compares the time intervals in the following pre-CPR conditions: the age of the patient; the previous health status of the patient; the disease underlying the CA; the site where CA occurs; the witnessing of the CA; the type of CA; the MICU center, responding to the CA. The mean introduction time is 4.6 min, the mean response time of BLS is 5.1 min, the mean duration of BLS before ALS is 11 min. Introduction in EMS should be improved in CA due to intoxication, drowning, SIDS and respiratory disease, and overall when CA occurs at home.
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PMID:Influence of pre-CPR conditions on EMS response times in circulatory arrest. The Cerebral Resuscitation Study Group. 255 Oct 19

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.
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PMID:Emergency medicine in France. 943 54

When EMS providers at both the BLS and ALS levels leave their training programs, they are armed with newfound knowledge, but they usually lack the appropriate life experiences to excel and survive on the streets. As these new providers enter the real world of EMS, they face the challenge of making life-and-death decisions in uncontrolled environments. This includes making the appropriate decisions while functioning effectively--even in potentially dangerous settings. The high job stress this creates often leads to burnout and, in many systems, high turnover rates. This need not be the situation, however, as field providers can learn to survive and excel in the streets by using the following nine rules.
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PMID:Staying on top--9 rules for surviving and excelling on the streets. 1014 1

There do exist several ALS techniques that could be performed by BLS personnel. With the proper training, EMTs can assist the paramedic with duties that can speed aid to the patient.
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PMID:The basically advanced provider. 1028 21

The present paper highlights quality aspects of the management of an Emergency Health Service Center (SSUEm 118, Varese) in order to identify the corrective measures required in a service that is increasingly close to the citizens real needs and expectations. Data were collected retrospectively on a total 54,301 calls for assistance in the period October 1997-March 1999 from an area covering some 1,300 sq.km with a population of 1,150,000 residents. That resident population was dramatically increased on a daily basis by heavy vehicle traffic particularly on the motorways to the area's many factories and to the Intercontinental Airport Malpensa 2000. The survey employed 7 anaesthetists and resuscitation staff, 14 nurses and 8 Italian Red Cross works from the Emergency Center. The researchers analysed the following phases: call reception and telephone conversation: ambulance dispatch, patient transportation and the alerting of the hospital of destination. The ServFMEA method was used for Quality Control with appropriate dispatch and the conduct and timing of the ambulance service in the Varese SSUEm 118 area. The data collected allowed for a detailed analysis of the accuracy of the information provided over the telephone (over-triage 58%, undertriage 2%), the usefulness of the telephone filter, the colour coding (correct in 40% of cases), pick-up times (5'40" on average) which were related to problems inherent in the ambulance call-out and the way ambulances reached the emergency (BLS 99%, ALS 1%, Air rescue < 1%). It was concluded that Varese SSUEm 118 was effectively and efficiently run in its first 18 months and results were improved as far as they could be given the inadequate funding of the Italian Heatlh Service.
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PMID:[Observing an SSU Em 118 dispatch center for continuous quality improvement. The case of SSUEm 118 Varese]. 1107 Sep 63


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