We're experimenting with this web page to offer new information, commentary and insight into the Emergency Medical Services. There are many sites on the WEB dealing with some aspects of EMS, but what we hope to offer here is a perspective of value to the physician who wants to learn more.
This is the second installment of a page which will be updated every few weeks. We would truly welcome your thoughts, your links to other sites, or commentaty you wish to share with your fellow internet physcians. Please feel free to e-mail with ideas fritzn@i- link.com
If you subscribe to the emergency discussion mailing list EMED-L, you noticed the string of ideas corcerns and comments about pre-hospital care providers performing needle crics. The original discussion began with a post by James Li, MD firstname.lastname@example.org
For consideration on the net. What do you feel about paramedics performing cricothyrotomies in the field for cases in which an airway cannot otherwise be obtained, where the patient would expire without an airway, and for which on- line medical control permission for such a procedure is readily avail- able? My question broadens to include needle decompression for patients suspected or found in the field to have tension pneumothoraces. Is there any national consensus as to what level of prehospital care such life-saving procedures can (or cannot) be administered, with readily available on-line (or in some cases, present-in-field) med- ical control?
Link here to read the entire post
After several days, Dr. Li posted a summary of ideas gathered:
Subject: emed-l Summary of query... Date: 16 May 95 12:53:22 -0700 Many thanks for the many responses to my query on the permissability of prehospital teams to perform cricothyrotomy and needle de compression in systems around the country. I would like to offer this summary of replies along with some comments. NEEDLE DECOMPRESSION Dr. Little (Columbus) makes a sound point that many trauma patients with unilaterally decreased breath sounds have pulmonary contusions not pneumothoraces, and as such suggests decompressing only those patients who are already intubated. In the cases of which I am aware in our system several patients were not intubated prior to decom pression but all had sustained penetrating rather than blunt trauma, leading the paramedics and medical control to believe that pneumo thoraces rather than contusions were to blame for dyspnea and poor or absent breath sounds. SUMMARY: Opinion was fairly positive on allowability of this proce dure in the prehospital setting with reports from the following areas: Seattle, Indianapolis, San Francisco, Toledo, Logan, Idaho, Arizona, District of Columbia, Maryland, Milwaukee, Boston. Also reporting allowability were Eastern Australia and South Africa (EMT- I level). CRICOTHYROTOMY Much discussion with many thoughtful points. I think Dr. Champion (Columbus) is correct in pointing out that cricothyrotomy is a high profile procedure which without proper quality control could be used overly frequently in a setting where other emergent airway measures might first be successfully applied. Dr. McNamara (Philadelphia) suggests one such technique, retrograde tracheal intubation which I have never attempted, but which several other residents in my group have successfully performed and subsequently dis cussed at our conferences. Another suggestion, transtracheal jet ventilation by Dr. Fotre (San Francisco) is not available to us in the prehospital setting because the pressure regulators needed to obtain 50 psi oxygen are not stocked on the ambulances.
Link to Dr. Champion's post (and others)
SUMMARY: Opinion was generally in favor of allowing paramedics, with on-line medical control and quality control, to perform this procedure. Four communities did not allow or determine a need for the procedure: Indianapolis, District of Columbia, Maryland (pending), and Cincinatti. Communities reporting in favor of paramedic cricothyrotomy: Seattle, San Francisco (needle only), Toledo, Boston, Logan, Idaho, Arizona, Milwaukee, Eastern Aus- tralia, and South Africa.
Link to a variety of posts from above communities.
In my own opinion (which I think is shared by the majority of the people who responded) both needle decompression and cricothyr- otomy are dramatic yet potentially lifesaving procedures. It is the dramatic aspect which necessitates proper monitoring and quality assurance, particularly by physician on-line control. It is nevertheless the potential lifesaving aspect which also nec essitates permitting prehospital personnel to use these procedures in those rare but terrible cases in which the choice is either the procedure or the patient's imminent death. If the issue is patient care, it seems a simple choice. As an endnote and response to those who have asked, we in New Orleans have been striving for some time to help out our EMS counterparts who suffer from tremendous resource strain due mostly to insufficient financing. Our EMS agency, NOHD, serves a population of 500,000 with a single-tier 6 ambulance group. During heavy periods, 2 additional units are sometimes available for a total of 8 units (7 paramedic, 1 intermediate). Annual call volume is 45,000, and average response time is 9 minutes. Acuity is terrific. As I stated in a letter-to-theeditor last month, I came from a similar sized city, Seattle, which in 1992 saw between two and three hundred victims of penetrating trauma. That year New Orleans saw between two and three thousand such victims. Including first response units, Seattle has 64 aid units at all times, with a 3 minute average response time. So, in similar sized cities, a factor of ten in acuity, tenth in available aid units, and three in average response time. Thanks again. It is wonderful to have such a forum for the aca- demic discussion of emergency medicine issues. James Li, MD Resident, Charity Hospital New Orleans
The EMS FAQ is a ZIP file
EMS WWW Sites list
The Galaxy Emergency Medical Services Page
University of Texas Health Science Center at San Antonio's Trauma Home Page
See theTraumaNet Home Page at Louisiana State University Medical Center
The OUHSC Cardiac Arrhythmia Advisory System
A new web page of Trauma Info this page focuses on trauamtic-stress and PTSD, but also includes mental health aspects of disaster response.
Christian Emergency Relief Team -- Volunteer Emergency medical Providers are needed around the world. This site includes details on some of CERT's needs and future medical trips.
This month's site of the month is Duke University Medical Center - Durham, NC
Hospital Web provides a list of all hospitals in the WWW.
The Virtual Hospital at the University of Iowa is a site in my home state. There is even a special section there for pediatrics .
"Radiology Cases In Pediatric Emergency Medicine" produced by Loren G Yamamoto, MD, MPH is available on the World Wide Web.
Multimedia Medical Reference On- Line
Global Emergency Medical Archives Featuring an interactive digest of postings to EMED-L.
HyperDOC A Multimedia/Hypertext Resource of the U.S. National Library of Medicine (NLM)
Health Info-com Medical Network Newsletter
Good Medicine Magazine is an educational publication on preventive medicine for better health. It combines "traditional" and "holistic" medicine.
The Pharmaceutical Information Network
The Morbidity & Mortality Weekly Report
Thank you for your visit. I am F.R. "Fritz" Nordengren, BA, NREMTP, EMS-I , the editor of the EMS page. Your story ideas and editorials are encouraged. Please e-mail me for details. I welcome your comments and suggestions at: Fritzn@i- link.com