-
Air Medical Journal 2023Air medical and critical care providers encounter the extremes of being both in-hospital and out-of-hospital clinicians, work in unpredictable environments, and treat... (Review)
Review
Air medical and critical care providers encounter the extremes of being both in-hospital and out-of-hospital clinicians, work in unpredictable environments, and treat patients with the most significant injury patterns and diagnoses. These demands highlight the need to recognize unique mental challenges for those who work in the air medical environment and the process by which providers make decisions. Patients who present with a high-acuity/low-volume pathology generate particularly difficult situations with abundant opportunity for both celebrations of performance and learning from mistakes. There are times when the desired option of therapy is not available, the most appropriate destination is not feasible, or the crew is unable to address every aspect of patient care with resources that are immediately available. Although it is logical to make decisions based on anatomic and physiological knowledge, the absence of an actual answer does not necessitate the acceptance of consensus. Dogmalysis refers to the dissolution of authoritative tenets held as established opinion without adequate grounds. This article highlights the importance of dogmalysis, the value of honest scientific reflection, and the aggressive seeking of evidence-based answers as it pertains to the air medical environment.
Topics: Humans; Consensus; Air Ambulances; Emergency Medicine
PubMed: 37356891
DOI: 10.1016/j.amj.2023.04.009 -
International Journal of Stroke :... Mar 2024Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the... (Review)
Review
BACKGROUND
Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed.
AIMS
To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services.
METHODS
We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary.
RESULTS
Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world.
CONCLUSION
Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.
Topics: Humans; Stroke; Ischemic Stroke; Thrombectomy; Ambulances; Reperfusion
PubMed: 37853529
DOI: 10.1177/17474930231210448 -
The Surgical Clinics of North America Apr 2024Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and... (Review)
Review
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
Topics: Humans; Emergency Medical Services; Hemorrhage
PubMed: 38453301
DOI: 10.1016/j.suc.2023.10.005 -
Annals of Emergency Medicine Jun 2024
PubMed: 38777506
DOI: 10.1016/j.annemergmed.2024.01.019 -
The New England Journal of Medicine May 2024Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. Whether very early blood-pressure control in the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. Whether very early blood-pressure control in the ambulance improves outcomes among patients with undifferentiated acute stroke is uncertain.
METHODS
We randomly assigned patients with suspected acute stroke that caused a motor deficit and with elevated systolic blood pressure (≥150 mm Hg), who were assessed in the ambulance within 2 hours after the onset of symptoms, to receive immediate treatment to lower the systolic blood pressure (target range, 130 to 140 mm Hg) (intervention group) or usual blood-pressure management (usual-care group). The primary efficacy outcome was functional status as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days after randomization. The primary safety outcome was any serious adverse event.
RESULTS
A total of 2404 patients (mean age, 70 years) in China underwent randomization and provided consent for the trial: 1205 in the intervention group and 1199 in the usual-care group. The median time between symptom onset and randomization was 61 minutes (interquartile range, 41 to 93), and the mean blood pressure at randomization was 178/98 mm Hg. Stroke was subsequently confirmed by imaging in 2240 patients, of whom 1041 (46.5%) had a hemorrhagic stroke. At the time of patients' arrival at the hospital, the mean systolic blood pressure in the intervention group was 159 mm Hg, as compared with 170 mm Hg in the usual-care group. Overall, there was no difference in functional outcome between the two groups (common odds ratio, 1.00; 95% confidence interval [CI], 0.87 to 1.15), and the incidence of serious adverse events was similar in the two groups. Prehospital reduction of blood pressure was associated with a decrease in the odds of a poor functional outcome among patients with hemorrhagic stroke (common odds ratio, 0.75; 95% CI, 0.60 to 0.92) but an increase among patients with cerebral ischemia (common odds ratio, 1.30; 95% CI, 1.06 to 1.60).
CONCLUSIONS
In this trial, prehospital blood-pressure reduction did not improve functional outcomes in a cohort of patients with undifferentiated acute stroke, of whom 46.5% subsequently received a diagnosis of hemorrhagic stroke. (Funded by the National Health and Medical Research Council of Australia and others; INTERACT4 ClinicalTrials.gov number, NCT03790800; Chinese Trial Registry number, ChiCTR1900020534.).
Topics: Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Ambulances; Antihypertensive Agents; Blood Pressure; Emergency Medical Services; Hypertension; Ischemic Stroke; Stroke; Time-to-Treatment; Acute Disease; Functional Status; China
PubMed: 38752650
DOI: 10.1056/NEJMoa2314741 -
BMJ Open Dec 2023Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response... (Review)
Review
OBJECTIVES
Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation.
DESIGN
A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included.
RESULTS
Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances.
CONCLUSIONS
Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.
Topics: Humans; Ambulances; Emergencies; Prospective Studies; Emergency Medical Services; Time
PubMed: 38101827
DOI: 10.1136/bmjopen-2023-073394 -
British Paramedic Journal Dec 2023The notion of a paramedic (as a title protected in law) has recently entered its third decade, but the history of the paramedic is considerably older than that. Who are...
The notion of a paramedic (as a title protected in law) has recently entered its third decade, but the history of the paramedic is considerably older than that. Who are we as a profession? What does it mean to be a paramedic? What makes us who we are? These intriguing and yet seldom asked philosophical questions are at the heart of this article, which is intended to provoke discussion and serve as a foundation for further inquiry into questions of identity and philosophy in paramedicine. Literature pertaining to paramedic professional identity was explored and contextualised within current paramedic practice. Although the overall picture is complex, four key areas for discussion emerged: the history of the paramedic profession; role diversity; the influence of ambulance work; and the education and training of paramedics. The influence of ambulance work permeates all areas, suggesting that it is central to the development of paramedic professional identity. This discussion article is an exploration of the unique contexts and experiences that are associated with the process of being and becoming for paramedics.
PubMed: 38046791
DOI: 10.29045/14784726.2023.12.8.3.42 -
International Journal of Biometeorology Oct 2023Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association... (Meta-Analysis)
Meta-Analysis Review
Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association between heat and ambulance dispatches. We conducted a systematic review and meta-analysis to retrieve and synthesise evidence published up to 31 August 2022 about the association between heat, prolonged heat (i.e. heatwaves), and the risk of ambulance dispatches. We initially identified 3628 peer-reviewed papers and included 48 papers which satisfied the inclusion criteria. The meta-analyses showed that, for each 5 °C increase in mean temperature, the risk of ambulance dispatches for all causes and for cardiovascular diseases increased by 7% (95% confidence interval (CI): 5%, 10%) and 2% (95% CI: 1%, 3%), respectively, but not for respiratory diseases. The risk of ambulance dispatches increased by 6% (95% CI: 4%, 7%), 7% (95% CI: 5%, 9%), and 18% (95% CI: 12%, 23%) under low-intensity, severe, and extreme heatwaves, respectively. We observed two potential sources of bias in the existing literature: (1) bias in temperature exposure measurement; and (2) bias in the ascertainment of ambulance dispatch causes. This review suggests that heat exposure is associated with an increased risk of ambulance dispatches, and there is a dose-response relationship between heatwave intensity and the risk of ambulance dispatches. For future studies assessing the heat-ambulance association, we recommend that (1) using data on spatially refined gridded temperature that is either very well interpolated or derived from satellite imaging may be an alternative to reduce exposure measurement bias; and (2) linking ambulance data with hospital admission data can be useful to improve health outcome classification.
Topics: Humans; Ambulances; Hot Temperature; Temperature; Hospitalization; Cardiovascular Diseases
PubMed: 37495745
DOI: 10.1007/s00484-023-02525-0