Disomy 1 with terminal 1p deletion is frequent in mass-screening-negative/late-presenting neuroblastomas in young children, but not in mass-screening-positive neuroblastomas in infants

OBJECTIVE: The need for valid and reliable emergency medical services (EMS) data has long been recognized. EMS data are useful for monitoring resources and operations, documenting patient care and outcome, and evaluating injury prevention strategies. The goal of this project was to develop a computerized data set with the capability to generate a patient care record (PCR) to overcome some of the current EMS data limitations. METHODS: The authors discuss developing an electronic PCR and analysis data set containing 233 variables. Data are collected for the following: incident, response, scene, patient, history, primary survey (including vital signs), physical examination, physiologic scores, diagnostics, plan (medications and procedures), assessment, and reevaluation. Software on a portable computer installed in an EMS response unit utilizes a graphical user interface for data collection by prehospital emergency care providers. A data set stores codes corresponding to user's selections. This data set supports data storage and analysis. The electronic PCR and data set can be useful to EMS agencies for collecting, storing, reporting, and analyzing information. RESULTS: Variables are categorized into 12 main categories to categorize the variables and to drive data collection. The system provides the user with the ability to print out a record (using a portable printer installed in an ambulance) and analyze data stored in the data set. CONCLUSION: This computerized approach overcomes many limitations inherent with using paper-based systems for research. Linked with emergency department, hospital discharge, and mortality data, EMS data can be used in systems analyses related to patient outcome.     

Serum sialic acid and its relationship to various haematological parameters, including erythrocyte sedimentation rate

Policies regarding ambulance diversion are critical to ensuring that EMS providers are aware of appropriate patient destinations, even before patients enter the system. Field EMS personnel should never be requested to prolong transport time intervals to search for an available hospital at the potential expense of patients' conditions and the immediate availability of out-of-hospital emergency care for the community. The responsibility for providing efficient emergency care to the community rests with all those who contribute to EMS structures and processes. All EMS system participants, including hospitals, EMS providers, local and regional lead agencies, and medical oversight authorities, must work together to create comprehensive ambulance diversion policies that satisfactorily meet each other's needs, while maintaining the highest regard for the needs of EMS patients and the entire community.     

The principal physician in emergency medicine

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.     

Emergency medical dispatching by general practitioners in Brussels

The objective of this study was to introduce general practitioners (GPs) to the existing emergency medical services (EMS) system, in order to improve the response to emergency residential calls. The study was based in Brussels, which has 1 million residents. A GP dispatcher (GPD) was placed in the emergency dispatch centre, with a stand-by GP, together with adequate equipment, at his or her immediate disposal. A comparative evaluation was conducted in 1994 to measure the changes brought by the availability of a stand-by GP to the emergency medical dispatching performed by the GPD in an experimental zone (EZ) in comparison with a control zone (CZ). The evolution between a first period at the beginning of the year and a second period in September was also analysed. In total, 1059 residential emergency calls were included in the study. The amount of missing data in the filing cards, collaboration between the emergency medical dispatcher (EMD) and the GPD, and evaluation of the emergency levels were improved by training the GPD and the stand-by GP. Intervention times of the stand-by GP varied according to the level of the emergency. The sending of supplementary assistance after dispatching an EMS ambulance, a stand-by GP or a GP of an on-call service was significantly different in the EZ compared with the CZ. The percentage of EMS ambulances and GPs sent increased. The evolution between the two periods was characterized in the CZ by the disappearance of the supplementary assistance performed by the stand-by GP or by the GP of the on-call service and in the EZ by a slight but not significant increased use of the mobile intensive care units (MICUs) for initial assistance. A stand-by GP was used in about 10% of the cases as supplementary assistance. A large number of non-vital urgent complaints arrive at the dispatch centre. The availability of a stand-by GP does not cause an increase (rather a decrease) in MICU use in initial care and supplementary assistance. It causes a decrease in the total EMS ambulances and transport to hospital and an increase in the use of EMS ambulances and stand-by GP as supplementary assistance. Following stand-by GP intervention, only 25% of visited people are hospitalized. Introduction of GPs is relevant because they are used to discerning critical events from a large number of non-critical disorders. The GPD can adapt the emergency medical dispatching by using a stand-by GP, without compromising the medical assistance to vital emergencies.     

Comparison of the time-action profiles of U40- and U100-regular human insulin and the rapid-acting insulin analogue B28 Asp

OBJECTIVE: Change from quality assurance (QA) to quality improvement (QI) in EMS has been adopted by many systems. This study sought to determine whether QI is effective in this setting. METHODS: A QI program comprised of prospective, concurrent, and retrospective components was instituted in 1994 by the Salt Lake City Fire Department. The retrospective component of the program consisted of monthly random audits of approximately 6% of EMS patient care reports (PCRs), both ALS and BLS. PCRs were evaluated for adequate documentation of six patient assessment parameters, appropriate treatment, and short-term outcome. Time intervals and adherence to protocol were also evaluated. Overall documentation and performance were rated. Monthly and cumulative QI reports were circulated to all providers, and both positive feedback and negative feedback were provided to specific crews. Continuing medical education sessions were tailored to address problems identified by the QI audits and scene observation. Results of 1,862 reviews from 1994-1995 were compared with baseline figures from 1993. RESULTS: Response, scene, and transport times were acceptable in more than 90% of cases in both the baseline and the study periods. Statistically significant improvements were noted in the following parameters: documentation of patient assessment, protocol compliance, patient disposition, overall documentation, overall performance, and need for further review. In nontransport cases, both appropriateness of the release decision and acquisition of appropriate signatures improved, but not significantly. CONCLUSION: Significant improvements were noted in 13 of 19 parameters and goals were met in 14, with results sustained over the two-year study period. A quality improvement program can effect significant and sustained improvement in documentation and performance in an EMS system.     

Upper gastrointestinal bleeding in an open-access dedicated unit

The open-access high dependency bleeding unit in Aberdeen admits all patients with suspected gastrointestinal bleeding from a stable adult population of 468,000. The aim is to reduce mortality, morbidity and hospital stay, and create a prospective whole community database. An agreed management protocol is based on prompt resuscitation and early diagnosis. From October 1991 to September 1993 there were 1,602 consecutive admissions with suspected upper or lower gastrointestinal haemorrhage. Bleeding was confirmed in 1,098 of 1,324 patients with presumed upper gastrointestinal haemorrhage, (117 bleeding episodes per 100,000 per year). The overall 30-day mortality was 3.9%, with all deaths attributable to significant concurrent illness. Mortality from peptic ulcer bleeding was 5.3%, with an operation rate of 17% and surgical mortality of 8%. Rapid diagnosis allowed 48% of 523 patients with trivial bleeds to be discharged after a median stay of 24 hours. Centralised expertise and equipment is the essence of the unit's success. The interests of patient care are better served, nursing skills are better developed and teaching opportunities better structured. The major improvement in clinical care, welcomed by hospital colleagues, management and general practitioners, makes the unit an indispensable part of acute medical provision.     

Predicting survival from out-of-hospital cardiac arrest: a graphic model

STUDY OBJECTIVE: To develop a graphic model that describes survival from sudden out-of-hospital cardiac arrest as a function of time intervals to critical prehospital interventions. PARTICIPANTS: From a cardiac arrest surveillance system in place since 1976 in King County, Washington, we selected 1,667 cardiac arrest patients with a high likelihood of survival: they had underlying heart disease, were in ventricular fibrillation, and had arrested before arrival of emergency medical services (EMS) personnel. METHODS: For each patient, we obtained the time intervals from collapse to CPR, to first defibrillatory shock, and to initiation of advanced cardiac life support (ACLS). RESULTS: A multiple linear regression model fitting the data gave the following equation: survival rate = 67%-2.3% per minute to CPR-1.1% per minute to defibrillation-2.1% per minute to ACLS, which was significant at P < .001. The first term, 67%, represents the survival rate if all three interventions were to occur immediately on collapse. Without treatment (CPR, defibrillatory shock, or definitive care), the decline in survival rate is the sum of the three coefficients, or 5.5% per minute. Survival rates predicted by the model for given EMS response times approximated published observed rates for EMS systems in which paramedics respond with or without emergency medical technicians. CONCLUSION: The model is useful in planning community EMS programs, comparing EMS systems, and showing how different arrival times within a system affect survival rate.     

A 10 year follow up of parenteral gold therapy in patients with rheumatoid arthritis

The objective of this study was the assessment of out-of-hospital cardiac arrest and the definition of possible predictive factors for final hospital discharge. Out of a database of 89,557 consecutive missions of the Vienna emergency medical system (EMS) during 1990, there were 623 missions due to a collapse of non-traumatic origin: in 374 cases (60.0%) the patients were declared dead without further attempts at resuscitation. The remaining 249 patients were analysed for predictive factors at site. Survival to hospital admission: 109 patients survived to hospital admission (43.7%); bystander support had a small impact (P < 0.05) on survival to hospital arrival whereas age and gender had no predictive power. Most patients with ventricular tachycardia/fibrillation (VT/VF) survived primarily (69 of 117, i.e. 59.0%). Survival to hospital discharge: 27 patients were discharged from hospital care (10.8%). ECG findings on arrival of the EMS physician at the site proved to be the only powerful predictor for survival: 24 of 117 patients with VT/VF survived compared with only one of 81 with primary asystole, two of 39 with severe bradycardia, and no patient with electromechanical dissociation.     

Quality management in emergency medicine

Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. In times of reduced funds for health care expenditures, quality management could be a reliable way to ensure that the EMS provides safe services to the patient based on the current state of medical science in an efficient manner. Based on clear definitions, structure, process, and outcome quality can be analysed, and the results provide the basis for continuous quality-improvement strategies. As not all aspects of the system can be analysed continuously, one has to select areas of special importance. External and internal quality control are equally important. Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.     

Bedwetting and psychopathology in adolescents

OBJECTIVE: To document the incidence, source, and reasons for all complaints received by a large municipal emergency medical services (EMS) program. METHODS: A retrospective review of all complaints received during three consecutive years (1990-1992) in a centralized EMS system serving a large municipality (population 2 million). All cases were categorized by year, source, and nature of the complaint. RESULTS: In the three study years, EMS responded to 416,892 incidents with nearly a half-million patient contacts. Concurrently, 371 complaints were received (incidence of 1.12 per thousand); 132 in 1990, 129 in 1991, and 110 in 1992. Most complaints involved either: 1) allegations of "rude or unprofessional conduct" (34%), 2) "didn't take patient to the hospital" (19%), or 3) "problems with medical treatment" (13%). Only 1.6% (n = 6) were response-time complaints. Other complaints included "lost/damaged property," "taken to the wrong hospital," "inappropriate billing," and "poor driving habits." The most common sources were patient's families (39%) and the patients themselves (30%). Only 7.8% were from health care providers. CONCLUSION: Reviews of complaints provide information regarding EMS system performance and reveal targets for quality improvement. For the EMS system examined, this study suggests a future training focus on interpersonal skills and heightened sensitivities, not only toward patients, but also toward bystanders and family members.     

Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults

BACKGROUND: Most paediatric cardiac arrest studies have been conducted in the USA, where paramedics provide prehospital emergency care. We wanted to study the outcome of paediatric cardiac arrest patients in an emergency medical system which is based on physician staffed emergency care units. METHODS: We analysed retrospectively the files of 100 prehospital cardiac arrest patients from Southern Finland during a 10-year study period. The patients were less than 16 years of age. RESULTS: Fifty patients were declared dead on the scene (DOS) without attempted resuscitation, and cardiopulmonary resuscitation (CPR) was initiated in 50 patients. The sudden infant death syndrome was the most common cause of arrest in the DOS patients (68%) as well as in those receiving CPR (36%). Asystole was the initial cardiac rhythm in 70% of the patients in whom CPR was attempted. Resuscitation was successful in 13 patients, 8 of whom were ultimately discharged. Six of the patients survived with mild or no disability and 4 of them had near-drowning aetiology. In multivariate analysis, the short duration of CPR (< or = 15 min) was the only factor significantly associated with better survival. CONCLUSIONS: Although prehospital care was provided by physicians, the overall rate of survival was found to be equally poor as reported from systems with paramedics. The only major difference between physician- and paramedic-staffed emergency care units is the ability of physicians to refrain from resuscitation already on the scene when prognosis is poor.     

Early defibrillation by emergency physicians or emergency medical technicians? A controlled, prospective multi-centre study

In a controlled, prospective multi-centre study, defibrillation by emergency medical technicians (EMTs) was compared with the current standard of care in Germany--defibrillation by emergency physicians (EPs)-in order to answer the following questions: can EMTs in a two-tiered emergency medical services (EMS) system with physicians in the field defibrillate earlier than, and as safely as EPs? Does defibrillation by EMTs (study group) affect survival rate and long-term prognosis of patients in ventricular fibrillation (VF), as compared with the current national standards in resuscitation (basic cardiopulmonary resuscitation (CPR) by EMTs, and defibrillation by physicians: control group? METHODS: Prior to the onset of the study, all EMTs completed retraining in basic life support (BLS). Randomly assessed EMTs were then trained to use semi-automatic defibrillators. With the help of on-line tape recordings, the complete resuscitation sequence was evaluated. Follow-up of the patients was carried out with the help of the Glasgow Coma Scale as well as Pittsburgh Cerebral and Overall Performance Categories. RESULTS: A total of 159 patients with VF were included in the study. In 121 cases, collapse was witnessed. Of the patients receiving defibrillation by EMTs 25% were discharged from hospital alive, compared to 24% of the patients defibrillated by EPs. Of the study patients 67% were defibrillated within 12 min, while the percentage of control patients was 46%. Study patients were defibrillated earlier (P < 0.01), the return of spontaneous circulation (ROSC) was achieved earlier (P < 0.05), and the rate of patients requiring no adrenalin during resuscitation was higher in the study group (P < 0.05). The total amount of adrenalin administered in the study group was lower (P < 0.05). No statistically significant differences were found concerning the neurologic long-term prognosis. CONCLUSIONS: In our study, EMT defibrillation was equally effective as defibrillation by EPs, but failed to improve survival rates or long-term outcome of patients in VF significantly, compared to EP defibrillation. Due to a reduction in the time intervals from collapse to defibrillation and to ROSC, as well as in adrenalin doses, by EMT-defibrillation, EMTs in Germany should defibrillate if they reach a patient prior to an EP, provided they have received continuous medical training and supervision.     

The issues of emergency medical system in patients with prehospital cardiac arrest complicating acute coronary syndrome in Japan

Each year approximately 30,000 persons in Japan experience prehospital cardiac arrest complicating acute coronary syndrome, and about 96 percent of them die. The majority of these sudden cardiac deaths are the result of fatal arrhythmias that often can be stopped by rapid initial medical care. In Tokyo, however, the first responder to provide cardiopulmonary resuscitation are about 10 percent, the successful defibrillation rate by Japanese paramedics who are not authorized advanced cardiac life support (ACLS) with drugs are about 15 percent and there are very few cardiologists who have been engaged in ACLS and initial management of suspected acute coronary syndrome in the emergency department. Therefore, each community emergency medical system should develop a plan to provide rapid initial medical care to patients with cardiac arrest (those with and without acute coronary syndrome).     

Modulation of biochemical activity of hepatocytes in culture by matrix substratum

If critical care nurses and advanced practice nurses could identify patients with an increased risk of an unsuccessful outcome from cardiac arrest resuscitation in the hospital, such patients could be monitored with a heightened vigilance. This is the first nursing study to examine pre-existing variables and outcome of cardiac arrest resuscitation in hospitalized patients. The investigators found that heart rate and respiratory rate increased significantly 8 hours before the cardiac arrest in patients with an unsuccessful outcome of resuscitation.     

The effect on central dopaminergic structures of various hydrazides of phosphorylated carbonic acids and diaziridines

STUDY OBJECTIVE: To describe the effectiveness of an emergency medical education program in a postwar developing country. METHODS: A prospective, nonrandomized interrupted time-series study was conducted in an emergency department at a national referral hospital in Rwanda immediately after the 1994 civil war. Participants included 11 medical personnel staffing the ED comprising physicians, nurses, and medical assistants. International medical relief workers in the ED identified deficiencies by directly observing routine clinical practices. On the basis of this assessment, formal training programs in trauma resuscitation, airway management, wound care, and blood/fluid precautions were conducted. Subjects were then observed 1 week and 2 months after the educational programs and scored on a standardized data-collection form. Scores before and after intervention were compared with the use of Fisher's exact test to determine program effectiveness. RESULTS: Educational interventions with statistically significantly longer term effects included wound management principles and blood/fluid precautions (before versus after intervention, P < .05). Interventions with the least sustained effect included advanced airway interventions and procedures related to trauma resuscitation. CONCLUSION: Educational seminars proved to have the greatest sustained effect on those behaviors requiring minimal equipment and noncomplex medical decisionmaking.     

Chromosome bands 3p14.2, 9p21, and 13q14 are frequently deleted in roentgenographically occult bronchogenic squamous cell carcinoma of the lung

This study was undertaken to determine whether melatonin (N-acetyl-5 methoxytryptamine) is effective in helping emergency medical services (EMS) personnel who work rotating night shifts reset their biological clocks and minimize circadian rhythm disruption. A double-blinded, randomized, crossover study was performed using 22 volunteers. Participants were working a span of consecutive night (2300 to 0700 hours) shifts and received either a melatonin capsule (6 mg) or placebo to be taken before each of the consecutive day sleeps. Each participant completed a total of 4 spans of consecutive night shifts (2 melatonin, 2 placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and drug side effects. Assessment of sleep quality, posttreatment mood, and workload ratings were measured daily by 10-cm visual analog scale (VAS). Analysis of sleep diaries found no significant difference (P > .05) between the two treatments with respect to mean sleep latency, duration, and efficiency, and subjectively rated sleep quality. Similarly, no significant benefits were noted between the median VAS scores for daily posttreatment mood or workload ratings. Adverse effects were rare; one patient taking melatonin reported a prolonged sedative effect. Despite recent interest in melatonin for treatment of circadian-based sleep disorders, no clinical benefits were noted in EMS personnel working rotating night shifts.     

Advantages and limitations of medical dispatching: the French view

One of the main features of the French emergency medical services (EMS) system as it has been developed during the last 40 years is the participation of a physician in each stage of the EMS organization. Thus, in the 100 French emergency medical dispatch centres, all calls received on 15, the national medical emergency phone number, are medically dispatched. The main advantages are: (i) better security for the caller; (ii) proper adaptation of the response to the emergency; (iii) a quicker and more efficient intervention time; (iv) the hospital is informed of the arrival of an emergency; (v) the respect of medical secrecy; (vi) a good cost-efficiency ratio in the use of intervention means. The main limitations are connected with: (i) the inaccuracy of certain calls and problems of dialogue with the caller; (ii) the poor acceptance of the system's obligations by some of the callers, patients, physicians or any other partners of the EMS organization. In the future the implementation of the multi-purpose European emergency number 112 will probably require the system's adaptation to it.     

Reaction of new Soviet immigrants to primary health care services in Israel

The post-1989 immigration wave from the former U.S.S.R. has increased the Israeli population by over 12 percent, seriously affecting the host health care system. This study draws on semi-structured interviews with the immigrants visiting outpatient clinics in the Tel-Aviv area in order to explore organizational and cultural aspects of their encounter with the Israeli medical services. While instrumental aspects of care were seen as an improvement over the Soviet standards, communication between providers and clients was seriously flawed, reflecting both a language barrier and diverse cultures of illness and cure. Many interviewees complained of the impersonal, "technical" attitude of Israeli physicians toward patients and the lack of holism in care, which they allegedly enjoyed before emigration. Some immigrant patients feel deprived of the paternalism of the Soviet medical system, complaining that Israeli providers "forego responsibility" for patients' health. A consumerist approach to medical services is also a novelty, and immigrants have to learn to be informed and assertive clients. Most problems are experienced by the elderly patients; overall, women seem to adjust to the new system better than men.     

A method to reduce response times in prehospital care: the motorcycle experience

This study compared the response times of a motorcycle and a standard ambulance in a congested urban emergency medical services (EMS) setting. The study was performed in Taipei, Taiwan, a densely populated urban area. A basic life support (BLS) motorcycle (without defibrillation capability) and an advanced life support (ALS) ambulance were based at three study hospitals and simultaneously dispatched when there was a perceived need for ALS ambulance transport. Over a 3-month period, prehospital personnel evaluated 307 medical and trauma emergencies. Time data were insufficient for analysis in 33 cases, leaving a study population of 274. Response times of the motorcycle and the ambulance were prospectively assessed and compared. During rush hours, the response times of the motorcycle and ambulance were 4.9+/-3.0 minutes and 6.3+/-3.4 minutes (P < .05), respectively, and in non-rush hours, 4.2+/-2.1 minutes and 5.1+/-2.5 minutes (P < .05), respectively. Using motorcycles to transport EMTs to the emergency scene significantly reduced response time compared with a standard ambulance in a congested urban setting. Large prospective studies are required to determine the impact on patient outcome of shorter EMS response times using motorcycles. EMS motorcycles appear feasible and deserve consideration to help expedite prehospital care in other systems in densely populated cities.     

Finite element analysis of trabecular bone structure: a comparison of image-based meshing techniques

OBJECTIVE: To report a qualitative evaluation of the Partnerships in Health Care/EMS Project between Poland and the United States. The goal of the partnership was to strengthen the emergency medical services (EMS) system in three Polish cities, Krakow, Bialystok, and Lodz. METHODS: The Polish participants were interviewed in Poland approximately eight months after a U.S.-based training program. They were asked to evaluate the effectiveness of the partnership project and discuss their experiences incorporating U.S. emergency medicine (EM) knowledge and technology in the Polish EMS system. RESULTS: The Polish physicians identified three major factors that had the greatest impact on the implementation of U.S. EM knowledge in Poland. These factors were the substantive differences between Polish and U.S. EM knowledge and technology, staffing differences in Polish and U.S. ambulances, and the differing role the EMS system plays in the delivery of primary care in the two countries. CONCLUSIONS: The Polish physicians succeeded in training EM providers in the three cities, thus strengthening clinical skills of EMS providers. They also were able to adapt the principles of U.S. EM that they had learned to fit the specific circumstances that characterize Polish emergency care. As in the United States, the health care system in Poland is inseparable from the social, political, and economic realities of the nation.