EMBBS EMS Homepage

Where the EMS community meets the Emergency Medical Community

Welcome!

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.

Guest Authors Wanted

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

EMED-L Discusses

Cricothyrotomy-- A Necessary Pre- Hospital Skill?

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 jli@nomvs.lsumc.edu

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

EMS Sites on the Web

The EMS FAQ is a ZIP file

EMS WWW Sites list

The Galaxy Emergency Medical Services Page

Trauma Section

University of Texas Health Science Center at San Antonio's Trauma Home Page

See theTraumaNet Home Page at Louisiana State University Medical Center

Cardiac Section

The OUHSC Cardiac Arrhythmia Advisory System

Links of the month

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.

Hospital Section

Hospital Site of the month

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.

Library and References

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.