Influence of Personal and Work Environments on Work-Life Balance Among Emergency Medical Technicians

Introduction Work-life balance (WLB) is a critical concern for emergency medical technicians (EMTs) because it significantly affects the provision of comprehensive emergency medical services (EMS). This study investigated personal and work-related factors influencing work-to-family negative spillover (WFNS), a key element of WLB, among EMTs. Methods A web-based survey was conducted from July 26 to September 13, 2021, among EMTs in Hokkaido, Japan. The study included 21 facilities that were randomly selected from 42 fire stations. The Japanese version of the Survey Work-Home Interaction-NijmeGen (SWING-J) was used to measure WFNS. Personal background factors, such as age, sex, years of work experience, and education, were surveyed. We also evaluated work environment factors, such as weekly working hours, monthly night shifts, monthly overtime hours, and yearly paid vacation days. Unpaired Student's t-tests, one-way analysis of variance (ANOVA), and multilevel generalized linear model (MGLM) analyses were used to explore the relationships between WFNS and personal and work-related factors. Results A total of 912 respondents were included in our analysis. They were predominantly male (98.2%), with an average EMT work experience of 12.7 years and a mean WFNS score of 1.16 (standard deviation (SD) = 1.67). MGLM analysis, adjusting for covariates, identified years of work experience (β = -0.129, p = 0.001), monthly overtime hours (β = 0.184, p < 0.001), and yearly paid vacation days (β = -0.170, p < 0.001) as independent factors associated with WFNS. Conclusion This study suggested that adjusting WFNS among EMTs could be achieved by reducing overtime hours and fostering an organized approach to paid leave within the work environment.

Inappropriate use of intravenous epinephrine leading to atrial fibrillation during prehospital anaphylaxis treatment: A case report

In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration for anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical service (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which isn't typically recommended for anaphylaxis without continuous monitoring. Since 2019, South Korea has initiated a pilot program to expand the EMT's scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director's comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.

Factors Predisposing Emergency Medical Technicians to Workplace Violence: A Cross Sectional Study

Emergency medical technicians (EMT) are at high risk of workplace violence as they often care for patients in uncontrolled and often hostile emergency settings. Gauteng Province, the most populous province in South Africa, caters for 75% of the total population which is dependant on state funded health care. Public sector EMTs' have been robbed with aggravated circumstances, assaulted with intent to do grievous bodily harm, raped and even murdered whilst on duty. Despite this, comprehensive studies investigating the factors that predispose public sector EMTs' to workplace violence in Gauteng Province are lacking. Thus, the aim of this study was to investigate the factors that predispose public service EMTs' to workplace violence in Gauteng Province. Data were collected using questionnaires. A total of 413 questionnaires were returned by community members of Gauteng who met the inclusion criteria. Descriptive statistics and binomial tests were used to analyze data. The results of this study revealed that workplace violence toward public service EMTs' in Gauteng is attributed to the high rates of crime, the widening gap of inequality, economic deprivation of basic rights to previously disadvantaged communities by government, vulnerability of EMTs' when responding to the ill and injured within low- and middle-income communities and a lack of consequence for disorderly behavior within the communities. An understanding of the community factors that predispose EMTs' to workplace violence may improve the understanding of the phenomenon of workplace violence and developing prevention programs within the communities.

Use of ketamine wafer for pain management by volunteer emergency medical technicians in rural Western Australia

OBJECTIVE

To describe the use of sublingual ketamine wafers administered by volunteer emergency medical technicians (EMTs) for pain management to patients in rural Western Australia (WA).

METHODS

This retrospective cohort study included patients older than 12 years who were attended by volunteer EMTs in Esperance, Lancelin and Kalbarri, WA and received analgesic medications from 2018 to 2021. Patients who received ketamine wafers with/without other analgesics were compared to (i) patients who received only oral paracetamol and (ii) patients who received inhalational methoxyflurane without ketamine wafers with/without paracetamol.

RESULTS

The present study included 826 patients, among whom 149 patients received ketamine wafer with/without other analgesics, 82 paracetamol only and 595 methoxyflurane with/without paracetamol. Patients who received ketamine wafers were younger (median age 49 years vs 54 years for the paracetamol group vs 58 years for the methoxyflurane group), required a longer median transport interval (56 min vs 20 min vs 8 min), trauma-related (73% vs 35% vs 54%), and presented higher median initial pain score (9 vs 3 vs 8 out of 10) than those who received paracetamol and those who received methoxyflurane, respectively. Eight in the ketamine wafers group (5.4%) had a record of nausea/vomiting after the administration of ketamine wafers.

CONCLUSIONS

Sublingual ketamine wafer was administered by volunteer EMTs without any evidence of major adverse events in rural WA and deemed useful as an additional pain management option when long transport to hospital was needed. No other symptoms that may be associated with the use of ketamine were recorded.

Emergency Medical Services in Taiwan: Past, Present, and Future

This review assessed the development of Taiwan's emergency medical services (EMS) and focused on the optimizing initiatives of the EMS systems, the current state of Taiwan's EMS system, EMS benchmarks in different regions of Taiwan, EMS response during the coronavirus disease 2019 (COVID-19) pandemic, and future design. In the past decade, there has been a noticeable increase in prehospital services, numerous optimizing initiatives to improve patient prognosis, and the medical oversight model. Taiwan's current EMS system, including the dispatch system, out-of-hospital cardiac arrest (OHCA) patient management, time-sensitive critical illness in prehospital settings, and disaster response, has undergone significant improvements. These improvements have been demonstrated to have a measurable impact on patient outcomes, as supported by medical literature. Each region in Taiwan has developed a unique EMS system with local characteristics, such as the implementation of the Global Resuscitation Alliance 10 steps for OHCA-related quality control, hearing automated external defibrillator program, a five-level prehospital triage system, an island-hopping strategy for patients with major trauma, dispatcher-assisted teamwork for OHCA resuscitation, and optimized prehospital care for acute coronary syndrome patients. In response to the COVID-19 pandemic from 2019 to 2023, Taiwan's EMS implemented measures to combat the outbreak such as interagency collaboration to obtain patient's personal information, to optimize prehospital management initiatives, and to provide financial compensation and personal insurance for emergency medical technicians. The areas that need focus include integrating prehospital and in-hospital information to build a national-level database (One-Stop Emergency Management), increasing public awareness of first responders and emergency casualty care, and evolving the EMS system by incorporating private EMS system, initiating school-based education of paramedicine, and legally recognizing paramedics as medical and health care personnel. By improving these areas, we can better prepare for the future and ensure that Taiwan's EMS system continues to provide high-quality care to those in need.

Expediting Treatment of Trauma Patients in the Emergency Department: Rapid Trauma Evaluation (RTE)

BACKGROUND

Criteria for trauma determination evolves. We developed/evaluated a Rapid Trauma Evaluation (RTE) process for a trauma patient subset not meeting preestablished trauma criteria.

METHODS

Retrospective study (July 2019 - May 2020) for patients either > 65 years with ground level fall within 24 hours or in a motorcycle collision (MCC) arriving by EMS not meeting ACS trauma-criteria. RTE process was immediate evaluation by nurse/EMT, room placement, physician notification, undressing/gowning, vital signs, head-to-toe assessment, upgrade trauma status. Number/type of admissions, discharges, trauma upgrades, LOS obtained via trauma-registry and chart-review. For comparison, historic controls (HC) were used [all patients meeting RTE criteria seen in the ED prior to RTE (Apr- June 2019)].

RESULTS

The RTE cohort (n=755) was 77% falls,23% MCCs, median age 82 [IQR 74-88] years; 42% male-Among falls, 3.2% required a modified-upgrade; 0.7% full-upgrade, 55% admitted [29.4% trauma). HC (n=575) was 92.3% falls, 7.7% MCCs, median age 81 (IQR: 67-88) years, 40.5% males-57.4% admitted (22% trauma). RTE MCC median age 42 (IQR:30-49) years, 84.4% male- 21.9% were upgraded [(6 modified-trauma; 1 full-trauma; 43.8% admitted (85.7% trauma)]. HC MCC median age 29 (IQR: 23-41) years, 95.5% male, 54.5% admitted (75% trauma]. No difference on demographics, admissions or discharges between groups (P>0.05) except HC MCC was younger (P<0.005). RTE median LOS was shorter than HC [203 (IQR: 147-278) minutes vs. 286 (IQR: 205-392) minutes, P<0.001].

CONCLUSIONS

Patients > 65 years with a ground level fall or in a MCC arriving via EMS not meeting ACS trauma criteria may benefit from RTE.

The Impact of the Addition of a Virtual Reality Trainer on Skill Retention of Tourniquet Application for Hemorrhage Control Among Emergency Medical Technician Students: A Pilot Study

INTRODUCTION

Trauma is a leading cause of preventable death in the United States. Emergency Medical Technicians (EMTs) often arrive first at the scene of traumatic injuries to perform life-saving skills such as tourniquet placement. While current EMT courses teach and test tourniquet application, studies have shown efficacy and retention of EMT skills such as tourniquet placement decay over time, with educational interventions needed to improve retention of skills.

METHODS

A prospective randomized pilot study was conducted to determine differences in retention of tourniquet placement among 40 EMT students after initial training. Participants were randomly assigned to either a virtual reality (VR) intervention or a control group. The VR group received instruction from a refresher VR program 35 days after initial training as a supplement to their EMT course. Both the VR and control participants' tourniquet skills were assessed 70 days after initial training by blinded instructors.  Results: There was no significant difference in correct tourniquet placement between both groups (Control, 63% vs Intervention, 57%, p = 0.57). It was found that 9/21 participants (43%) in the VR intervention group failed to correctly apply the tourniquet while 7/19 of the control participants (37%) failed in tourniquet application. Additionally, the VR group was more likely to fail the tourniquet application due to improper tightening than the control group during the final assessment (p = 0.04).  Conclusion: In this pilot study, using a VR headset in conjunction with in-person training did not improve the efficacy and retention of tourniquet placement skills. Participants who received the VR intervention were more likely to have errors relating to haptics, rather than procedure-related errors.

Evaluation of the seroprevalence of measles, rubella, mumps, and varicella and the requirement for additional vaccination based on the JSIPC guidelines among emergency medical technicians at eight fire stations in Narita, Japan: a project review

Limited data are available regarding the seroprevalence of measles, mumps, rubella, and varicella (MMRV) among emergency medical technicians (EMTs) in Japan. The present study aimed to review a project to evaluate adequate immunity against MMRV for the requirement of additional vaccination among EMTs in accordance with the Japanese Society for Infection Prevention and Control guidelines. A retrospective observational study was conducted as part of a vaccination program for EMTs. Each participant was evaluated for medical history, vaccination history, and serology using the criteria established by the Japanese Society of Infection Prevention and Control. In total, 85 EMTs (median age, 31 years; male, 92.9%) were included. Among the included EMTs, 32 (37.6%), 54 (63.5%), 46 (54.1%), and 84 (98.9%) were seropositive for measles, rubella, mumps, and varicella, respectively, whereas 1 (1.2%), 6 (7.1%), 5 (5.9%), and 0 (0%) were seronegative. Furthermore, 48 (56.5%), 27 (31.8%), 45 (52.9%), and 8 (9.4%) EMTs received an additional dose of vaccines for measles, rubella, mumps, and varicella, respectively. The present study suggests that EMTs are not fully immune to MMRV, which highlights the need for confirming the immune status and additional vaccination requirement to prevent occupational infections.

The Effects of Interactive eBooks on Dyspnea Assessment and Management among Emergency Medical Technicians: A Repeated-Measures Analysis

Dyspnea is a common emergency requiring urgent care, and a variety of factors may mislead emergency medical technicians (EMTs). Typically, EMT education uses traditional lectures with paper books. The effect of interactive eBooks on EMT learning has not been explored. This study aims to develop an interactive eBook in dyspnea assessment and management and to evaluate its learning effect. A quasi-experimental design with three repeated measures was used. A total of 117 EMTs were recruited and assigned to the experimental group (eBook, n = 56) and the comparison group (paper book, n = 61). Questionnaires were administered to both groups at three time points. The results show that both materials can improve cognition and that the interactive eBook has better effects than the paper book. The interactive eBook motivated EMT to learn more than the paper book, but motivation did not last for five weeks. The long-term effect of the interactive eBook on confidence compared to the paper book is significant. The eBook can include real cases, concept maps, videos, quizzes, and instant feedback to meet learner needs. Health educators could integrate technology and cognitive strategies into EMTs’ training curricula to improve their ability to provide better emergency medical services.

Emergency Medical Technician Training in Medical School on Preparation for Required National Board Exams and Clerkship Rotations: Results from a Student Survey

PURPOSE

The University of South Carolina School of Medicine Greenville has incorporated Emergency Medical Technician (EMT) training into the first semester curriculum with students becoming state-certified EMTs and completing one ambulance shift per month throughout their pre-clerkship years. Although there have been programs that have reported EMT experiences in the pre-clinical years of medical education, student perceptions of how the EMT experiences help prepare them for board exams and clerkships is limited. Therefore, the aim of this study was to measure student perceptions regarding the impact of an EMT course and training in the pre-clerkship curriculum in medical school on helping prepare them for national board exams (ie USMLE^® Step 1, 2 Clinical Knowledge (CK), 2 Clinical Skills (CS)) and clerkship rotations.

METHODS

Second-, third-, and fourth-year medical students at the University of South Carolina School of Medicine Greenville completed an anonymous voluntary survey with response rates of 66.3%, 55.2%, and 56.9%, respectively. The study was reviewed and exempted by the University of South Carolina Institutional Review Board.

RESULTS

Seventeen percent, 14%, and 41% of students agreed/strongly agreed an EMT course helped prepare them for the USMLE Step 1, Step 2 CK, and Step 2 CS exam, respectively. Sixty-four percent of students agreed/strongly agreed that an EMT course and experience helped prepare them for clerkship rotations.

CONCLUSION

The findings in this study support EMT training and experience as an EMT as one method to help prepare students for clerkship rotations.

Approaches of 112 ambulance service staffers to children with burns: A survey assessment

BACKGROUND

We aimed to evaluate the knowledge of 112 ambulance service staffers (doctors, nurses, emergency medical technicians [EMTs], and paramedics [PMs]) who were the first intervention to pediatric patients with burn injuries regarding first intervention and patient transfer.

METHODS

The study included 373 personnel working in 112 ambulance services in Ankara province. Participants were asked 17 questions to measure their knowledge of burns in children. Statistical analysis was performed with the Statistical Package for Social Sciences 21.0.

RESULTS

Of the participants, 26 (7%) were doctors, 25 (6.7%) nurses, 180 (48.3%) EMTs, and 142 (35.3%) PMs. Of the participants, 118 stated that they always calculate the burn surface area, while only five (1.3%) marked the correct choice of the Lund Browder scheme to the question by which method they calculated. One hundred twenty one personnel (32.4%) use the Parkland formula to calculate the amount of fluid to be given during transfer while only 7 (1.9%) use the Galveston formula, which is more suitable for chil-dren. Of the participants, 56 (15%) answered as lactated Ringer's solution which is the correct fluid to the question of which fluid do you give at the scene and during the transfer. One hundred fifty-three participants (41%) responded correctly to the scenario question expected to recognize inhalation damage while only 138 (37%) responded correctly as 'I do immediately intubate' to the inhalation injury described scenario question. One out of 373 (0.3%) participants marked the appropriate procedure for a patient who had a 50% scald burn during the first intervention and transfer. The rate of topical lidocaine use of participants was high (70.8%). Of the 373 participants, only 33 (8.8%) thought themselves competent for first aid and transfer of children with burns. If training on the subject was held, 333 personnel (89.3%) wanted to participate.

CONCLUSION

It is expected that the knowledge of 112 ambulance services who see pediatric burn patients first, perform the first intervention, and provide transfer would be suitable. However, our questionnaire shows that these personnel have insufficient knowledge and need to be trained.

A model to explain the challenges of emergency medical technicians' decision making process in emergency situations: a grounded theory

BACKGROUND

To manage life-threatening conditions and reduce morbidity and mortality, pre-hospital's on-scene decision making is an influential factor. Since pre-hospital's decision making is a challenging process, it is necessary to be identified this process. This study was conducted to explore the model of Iranian emergency medical technicians' decision making in emergency situations.

METHODS

This study was applied through grounded theory method using direct field observations and semi-structured interviews. Purposeful sampling with 26 participants including 17 emergency medical technicians including dispatchers, physicians of medical directions, managers and 1 representative for court affairs was performed. Interviews were lasted from October 2018 to July 2019. Corbin and Strauss approach, 2015 (open, axial and selective coding) were used to analyze data.

RESULTS

A paradigm model was developed to explain the relationships among the main categories. Decision making in the context of fear and concern was emerged as the core category. Unclear duties, insufficient authorities and competencies as well as lack of enough decision making's protocols and guidelines were categorized as casual conditions. Other important categories linked to the core category were interactions, feelings and "customer focus approach". Action-interaction strategies were taken by Emergency Medical technicians lead to some negative consequences that can threaten clinical outcome and patient safety.

CONCLUSIONS

Based on the finding of this study, Emergency Medical technicians' decision making in the context of fear and concern, as the core concept of this model, lead to decrease in quality of the pre-hospital services, stakeholders' dissatisfaction, hospital emergency units' overload, decrease in reputation of the Emergency Medical Technicians, threat to patient clinical outcome and patient safety. To prevent of these negative consequences, facilitation of the Emergency Medical Technicians' on-scene decision making is recommended.

The Relationship Between Death Anxiety and Alexithymia in Emergency Medical Technicians

INTRODUCTION

When confronted with traumatic accidents and events that result in death, people are at risk of developing death anxiety. Due to their stressful job, emergency medical technicians (EMTs) will develop alexithymia and be unable to express and manage their emotions over time. Studies show that alexithymia causes physical and mental disorders in many people. The present study aimed to determine the relationship between death anxiety and alexithymia in EMTs.

METHODS

The convenience sampling method was used to select 400 EMTs in southeastern Iran who met the inclusion criteria for this descriptive-analytical study. The Templer Death Anxiety Scale and the Toronto Alexithymia Scale were used to collect data. SPSS version 20 was used to analyze the data, which included descriptive and analytical statistics (Independent t test, ANOVA, Pearson correlation, and regression).

RESULTS

The results of the study showed that the mean score of death anxiety in EMTs was 10.26 ± 3.69. It was revealed that 46.7% of the EMTs experienced severe death anxiety. Furthermore, the total mean score of alexithymia in EMTs was 59.65 ± 8.28, indicating the possibility of alexithymia. The Pearson correlation test showed a direct moderate relationship between death anxiety and alexithymia scores (r = .351, p < .001).

CONCLUSION

According to the results, there is a direct significant relationship between death anxiety and alexithymia in EMTs. Therefore, it is suggested that EMTs be continuously taught effective methods to deal with death anxiety and reduce the physical and mental disorders caused by this problem.

Paramedic and EMT Program Performance on Certification Examinations Varies by Program Size and Geographic Location

Introduction: The quality of an Emergency Medical Technician (EMT) or paramedic training program is likely one factor that contributes to a candidate's success on the National Registry Cognitive Examination. However, program pass rates and their associated geographic location have not previously been evaluated. Our objective was to evaluate the performance of EMT and paramedic programs in the United States, pass rates on the National Registry Cognitive Examinations, and relationship to geography.Methods: We conducted a cross-sectional evaluation of EMT and paramedic programs' first and cumulative third attempt pass rates on the National Registry Cognitive Examination in 2015. Included were civilian EMT and paramedic programs with >5 graduates testing for certification. Descriptive statistics were calculated for program pass rates, total graduates testing, and pass rates by National Association of State EMS Officials (NASEMSO) regions.Results: We included 1,939 EMT programs (6-1,892 graduates testing/program) and 602 paramedic programs (6-689 graduates testing/program). We excluded 262 (11.9%) EMT and 51 (7.8%) paramedic programs with ≤5 graduates testing annually due to unstable estimates of program pass rates. EMT programs in the highest quartile for total number of graduates testing outperformed the lowest quartile in both first attempt (65.7% vs. 61.9%, p < 0.001) and cumulative third attempt pass rates (79.1% vs 72.7%, p < 0.001). This difference was also seen for paramedic programs on first attempt (77.3% vs. 62.5%, p < 0.001) and cumulative third attempt (91.9% vs. 76.9%, p < 0.001). EMT program pass rates for first and cumulative third attempts also varied by NASEMSO region (first: 62-68%; third: 74-78%) with the Great Lakes and West regions outperforming the other regions. Paramedic program pass rates differed by NASEMSO regions as well (first: 65-83%; third: 81-95%) with highest pass rates in the West region.Conclusions Program performance for both EMT and paramedic programs varies by total number of graduates testing and geographic location. Graduates from larger EMT and paramedic programs have higher first and cumulative third attempt pass rates compared to graduates from smaller programs. Additionally, there is variability in program pass rates across NASEMSO regions for both certification levels. Further evaluation is necessary to better understand the variability in program performance in the United States.

Dextrose 50% versus Dextrose 10% or Dextrose Titration for the Treatment of Out-of-Hospital Hypoglycemia: A Systematic Review

INTRODUCTION

Paramedics commonly administer intravenous (IV) dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may cause harm and lead to difficulties regulating blood glucose levels (BGLs) post-treatment. It is hypothesized that a lower concentration, such as 10% dextrose (D10), may improve symptoms while minimizing harm.

METHODS

PubMed, Embase, CINAHL, and Cochrane Central were systematically searched on September 15, 2020. The PRISMA guidelines were followed. GRADE and risk of bias were applied to determine the certainty of the evidence. Primary literature investigating the use of IV dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department was included. Outcomes of interest included safety, efficacy (symptom resolution), and BGL.

RESULTS

Of 680 abstracts screened, 51 full-text articles were reviewed, with eleven studies included. Data from three randomized controlled trials (RCTs) and eight observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies, there was greater symptom resolution in the D10 group (95.9%) compared to the D50 group (88.8%). However, the mean time to resolution was approximately four minutes longer in the D10 group (4.1 minutes [D50] versus 8.0 minutes [D10]). There was a greater need for subsequent doses with the use of D10 (19.5%) compared to D50 (8.1%). The post-treatment glycemic profile was lower in the D10 group at 6.2mmol/L versus 8.5mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia: 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/1057) compared to 13/310 adverse events in the D50 group.

CONCLUSION

Studies show D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer, there appear to be fewer adverse events. The post-D10-treatment BGL may result in fewer untoward hyperglycemic episodes.

Barriers and requirements in the off-line emergency medical protocols implementation in Iranian Pre-hospital system: A qualitative study

BACKGROUND

To avoid making decisions based on the unproven opinions of emergency medical technicians (EMTs), many emergency medical service (EMS) systems rely on emergency medical protocols. As protocol-based on-scene decision-making is influenced by many challenges, identifying these challenges can result in providing appropriate conditions for EMTs' decision-making. Therefore, this study aimed to identify the barriers and requirements in the off-line emergency medical protocols implementation m in the prehospital emergency medical system.

MATERIALS AND METHODS

To conduct this study, qualitative content analysis using 10 field observations, 22 interviews, and 2 rounds of focus group discussions was applied. The duration of interviews lasted from October 2019 to January 2020. The Graneheim and Lundman approach was used to analyze the data.

RESULTS

Seven categories (15 subcategories) including education and awareness (professional training and education and community-based education); attitudes (professional attitude and community attitude); interactions and coordination (interpersonal interactions, organizational interferences, and community's interactions); rules and instructions (instructions and supportive rules); control system (monitoring and evaluation and motivational system); accessibility (recourses and communication); and organization (structure and process) were obtained as the obstacles and challenges in the offline emergency medical protocol implementation in the prehospital system.

CONCLUSIONS

There are many challenges in implementing offline emergency medical protocols in the prehospital emergency system. To achieve the effectiveness and efficiency of offline prehospital emergency protocols, it is necessary to facilitate these challenges and improve the EMTs' knowledge, attitude, and performance through cooperative and skill-based education. The findings of this study can be useful for EMS systems from national to local levels.

Professional codes of conduct: A scoping review

BACKGROUND

Professional ethical codes are an important part of healthcare. They are part of the professionalisation of an occupation, are used for regulation of the professions and are intended to guide ethical behaviour in healthcare. However, so far, little is known about the practical use of professional codes in healthcare, particularly in paramedicine.

OBJECTIVE

The aim of this scoping review was to determine what is known in the existing literature about health professionals' knowledge, awareness and use of their professional codes.

METHOD

A scoping review was performed based on a six-stage framework as described by Levac et al. Six databases were searched: OVID Medline, EMBASE, EMCARE, CINAHL, ProQuest and Scopus, in September 2020. Google Scholar, Trove and Google using .gov and .org websites were also searched for grey literature. Two reviewers independently assessed study eligibility.

RESULTS

The search yielded 1162 results after duplicate removal. Thirty-nine studies remained after title and abstract review. Twenty-five articles were included after full-text review. Sixteen examined nursing, eight examined medicine and one examined both nursing and medicine. No studies were identified that examined paramedicine. Twenty-one studies were of a cross-sectional design and four studies were of a qualitative design.

CONCLUSION

Most health professionals know the codes exist, but do not think they know the content. Despite valuing professional codes highly, healthcare professionals do not use them regularly in clinical practice. Further research is needed, and professional codes should be made useful for practice and consideration given to how codes can be written, communicated and implemented to increase their actualisation in healthcare. Research should also begin in paramedicine to identify clinician's knowledge and use of codes in this profession.

REVIEW REGISTRATION

Open Science Framework - doi:10.17605/OSF.IO/NKBY4.

ETHICS STATEMENT

This article does not contain any studies involving human participants performed by any of the authors. The review followed good scientific conduct.

Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study

Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians' destination decision-making for pediatric patients. We also sought EMS clinicians' opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis.  Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals' pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals' pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.

Emergency medical services education research priorities during COVID-19: A modified Delphi study

OBJECTIVE

Our objective was to identify research priorities to understand the impact of COVID-19 on initial emergency medical services (EMS) education.

METHODS

We used a modified Delphi method with an expert panel (n = 15) of EMS stakeholders to develop consensus on the research priorities that are most important and feasible to understand the impact of the COVID-19 pandemic on initial EMS education. Data were collected from August 2020 to February 2021 over 5 rounds (3 electronic surveys and 2 live virtual meetings). In Round 1, participants submitted research priorities over 9 specific areas. Responses were thematically analyzed to develop a list of research priorities reviewed in Round 2. In Round 3, participants rated the priorities by importance and feasibility, with a weighted score (2/3*importance+1/3*feasibility) used for preliminary prioritization. In Round 4, participants ranked the priorities. In Round 5, participants provided their agreement or disagreement with the group's consensus of the top 8 research priorities.

RESULTS

During Rounds 1 and 2, 135 ideas were submitted by the panel, leading to a preliminary list of 27 research priorities after thematic analysis. The top 4 research priorities identified by the expert panel were prehospital internship access, impact of lack of field and clinical experience, student health and safety, and EMS education program availability and accessibility. Consensus was reached with 10/11 (91%) participants in Round 5 agreeing.

CONCLUSIONS

The identified research priorities are an important first step to begin evaluating the EMS educational infrastructure, processes, and outcomes that were affected or threatened through the pandemic.

Associations between sleep, stress, and cardiovascular health in emergency medical services personnel

OBJECTIVE

Our objective was to quantify the associations between sleep duration and perceived and chronic stress with ideal cardiovascular health (CVH) among emergency medical services (EMS) personnel from county-based EMS agencies.

METHODS

We conducted a cross-sectional survey of cardiovascular disease (CVD)-free EMS personnel from 4 US EMS agencies. The questionnaire consisted of the Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale (PSS), Chronic Burden Scale, and the CVH components (smoking, body mass index, physical activity, diet, blood glucose, blood pressure, cholesterol, each scored 0-2 points). The components were summed and ideal CVH considered 11-14 points. Mixed effects logistic regression models with a random intercept for agency were used to estimate the odds of ideal CVH for good sleep quality (PSQI < 5 points), recommended sleep duration (7 to < 9h), low perceived stress (PSS < 26 points), and low chronic stress (0 recent stressful events).

RESULTS

We received 379 responses (response rate = 32%). There was low prevalence of good sleep quality (23%) and recommended sleep duration (25%), but 95% reported low perceived stress, and 33% had low chronic stress. Ideal CVH was reported by 30%. No significant associations between ideal CVH and sleep quality, perceived stress, or chronic stress were found. There was a nearly 2-fold increase in the odds of ideal CVH with recommended sleep duration (odds ratio: 1.83, 95% confidence interval: 1.08-3.10).

CONCLUSION

In this sample of EMS personnel, only recommended sleep duration was associated with ideal CVH. Future longitudinal studies are needed to understand the relationship between sleep, stress, and CVD in this understudied occupational group.

Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review

Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting.

Exertional Heat Stroke Knowledge and Management among Emergency Medical Service Providers

This study evaluated emergency medical services (EMS) providers' knowledge of exertional heat stroke (EHS) and assessed current EMS capabilities for recognizing and managing EHS. EMS providers currently practicing in the United States were recruited to complete a 25-item questionnaire. There were 216 questionnaire responses (183 complete) representing 28 states. On average, respondents were 42.0 ± 13.0 years old, male (n = 163, 75.5%), and white (n = 176, 81.5%). Most respondents were Paramedics (n = 110, 50.9%) and had ≥16 years of experience (n = 109/214, 50.9%) working in EMS. Fifty-five percent (n = 99/180) of respondents had previously treated a patient with EHS. The average number of correct answers on the knowledge assessment was 2.6 ± 1.2 out of 7 (~37% correct). Temporal (n = 79), tympanic (n = 76), and oral (n = 68) thermometers were the most prevalent methods of temperature assessment available. Chemical cold packs (n = 164) and air conditioning (n = 134) were the most prevalent cooling methods available. Respondents demonstrated poor knowledge regarding EHS despite years of experience, and over half stating they had previously treated EHS in the field. Few EMS providers reported having access to an appropriate method of assessing or cooling a patient with EHS. Updated, evidence-based training needs to be provided and stakeholders should ensure their EMS providers have access to appropriate equipment.

First Responder Resiliency ECHO: Innovative Telementoring during the COVID-19 Pandemic

The First Responder ECHO (Extension for Community Outcomes) program was established in 2019 to provide education for first responders on self-care techniques and resiliency while establishing a community of practice to alleviate the enormous stress due to trauma and substance misuse in the community. When the SARS-CoV-2 (COVID-19) pandemic hit the United States (US) in March 2020, a tremendous strain was placed on first responders and healthcare workers, resulting in a program expansion to include stress mitigation strategies. From 31 March 2020, through 31 December 2020, 1530 unique first responders and frontline clinicians participated in the newly expanded First Responder Resiliency (FRR) ECHO. The robust curriculum included: psychological first aid, critical incident debriefing, moral distress, crisis management strategies, and self-care skills. Survey and focus group results demonstrated that, while overall stress levels did not decline, participants felt more confident using psychological first aid, managing and recognizing colleagues who needed mental health assistance, and taking time for self-care. Although first responders still face a higher level of stress as a result of their occupation, this FRR ECHO program improves stress management skills while providing weekly learning-listening sessions, social support, and a community of practice for all first responders.

Remote certification of out-of-hospital deaths in a Canadian Province: An 8-year experience of a novel practice

Introduction:

Certification of out-of-hospital deaths is challenging as physicians are often unavailable at the scene. In these situations, emergency medical services will generally transport the decedent to the nearest hospital. In 2011, a remote death certification program was implemented in the province of Québec, Canada. The program was managed through an online medical control center and enabled death certification by a remote physician. We sought to evaluate the implementation and feasibility of the remote death certification program and to describe the challenges we experienced.

Methods:

We retrospectively reviewed all remote death certification requests received at the online medical control center between 2011 and 2019. Data were collected from the online medical control center database and records. Feasibility was determined by evaluating the remote death certification rate.

Results:

Overall, 84.1% of remote death certification requests were realized, producing a total of 9776 death certificates. Male decedents accounted for 61.5% of remote death certification requests and were more likely than females to undergo a coroner’s investigation for cause of death (36.3% vs 20.8%, p = 0.017). Urban/mixed regions had higher rates of achieved remote death certifications (mean 87.3% vs 76.9%, p = 0.033) and putrefied bodies (mean 3.8% vs 2.2%, p = 0.137) compared to rural regions. Among unrealized remote death certification requests, the most common reason was failure of relatives to designate a funeral home (36.8%).

Conclusion:

Our 8-year experience with the remote death certification program demonstrates that despite facing numerous challenges, this process is feasible and offers a valuable option to manage out-of-hospital deaths. The remote death certification program is spreading in the remaining regions of Québec. Future studies will aim to quantify how much time this process saves for emergency medical services in each region of the province.

The feasibility of emergency medical technicians performing intermittent high-quality cardiopulmonary resuscitation

Background: Whether intermittent chest compressions have an effect on the quality of CPR is worthy of discussion. The purpose of this study was to investigate differences in the chest compression quality of emergency medical technicians (EMTs) performing cardiopulmonary resuscitation (CPR) with different rest intervals. Methods: Seventy male firefighters with EMT licenses participated in this study. Participants completed body composition measurements and three CPR quality tests, as follows: (1) CPR-uninterrupted for 10 minutes; (2) after 2 days of rest, CPR 10s-intermittent (CPR-10s), for 2 minutes each time and 5 cycles; (3) after another 2 days of rest, CPR 20s-intermittent (CPR-20s), for 2 minutes each time and 5 cycles. Results: Body composition results showed that body mass (BM), body mass index (BMI), upper limb muscle mass (ULMM), core muscle mass (CMM), and upper limb-core muscle mass (UL+CMM) were positively correlated with chest compression depth (CCD) (p < 0.05). Analysis of the three different modes of CPR quality analysis indicated significant differences in the chest compression fraction (CCF, F = 6.801, p = 0.001), chest compression rebound rate (CCRR, F = 3.919, p = 0.021), and ratings of perceived exertion (RPE, F = 23.815, p < 0.001). Among the different performance cycles of CPR-10s, significant differences were found in CCF, CCD, CCR (chest compression rate), and RPE (p < 0.05). On the other hand, among the different performance cycles of CPR-20s, significant differences were found in CCD, CCR, and RPE (p < 0.05). Moreover, the CCF, CCD, and RPE scores of the two tests reached significant differences in specific phases (p < 0.05). Conclusions: This study confirmed that the upper limb muscle mass or the weight of the upper body of EMTs is positively correlated with the quality of CPR. In addition, intermittent chest compressions with safe interruption intervals can reduce fatigue caused by long-term chest compressions and maintain better chest compression quality.

12-Lead Electrocardiograms Acquired and Transmitted by Emergency Medical Technicians are of Diagnostic Quality and Positively Impact Patient Care

INTRODUCTION

Existing peer-reviewed literature describing emergency medical technician (EMT) acquisition and transmission of 12-lead electrocardiograms (12L-ECGs), in the absence of a paramedic, is largely limited to feasibility studies.

STUDY OBJECTIVE

The objective of this retrospective observational study was to describe the impact of EMT-acquired 12L-ECGs in Suffolk County, New York (USA), both in terms of the diagnostic quality of the transmitted 12L-ECGs and the number of prehospital percutaneous coronary intervention (PCI)-center notifications made as a result of transmitted 12L-ECGs demonstrating a ST-elevation myocardial infarction (STEMI).

METHODS

A pre-existing database was queried for Emergency Medical Services (EMS) calls on which an EMT acquired a 12L-ECG from program initiation (January 2017) through December 31, 2019. Scanned copies of the 12L-ECGs were requested in order to be reviewed by a blinded emergency physician.

RESULTS

Of the 665 calls, 99 had no 12L-ECG available within the database. For 543 (96%) of the available 12L-ECGs, the quality was sufficient to diagnose the presence or absence of a STEMI. Eighteen notifications were made to PCI-centers about a concern for STEMI. The median time spent on scene and transporting to the hospital were 18 and 11 minutes, respectively. The median time from PCI-center notification to EMS arrival at the emergency department (ED) was seven minutes (IQR 5-14).

CONCLUSION

In the event a cardiac monitor is available, after a limited educational intervention, EMTs are capable of acquiring a diagnostically useful 12L-ECG and transmitting it to a remote medical control physician for interpretation. This allows for prehospital PCI-center activation for a concern of a 12L-ECG with a STEMI, in the event that a paramedic is not available to care for the patient.

A review of ventilation in adult out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest continues to be a devastating condition despite advances in resuscitation care. Ensuring effective gas exchange must be weighed against the negative impact hyperventilation can have on cardiac physiology and survival. The goals of this narrative review are to evaluate the available evidence regarding the role of ventilation in out-of-hospital cardiac arrest resuscitation and to provide recommendations for future directions. Ensuring successful airway patency is fundamental for effective ventilation. The airway management approach should be based on professional skill level and the situation faced by rescuers. Evidence has explored the influence of different ventilation rates, tidal volumes, and strategies during out-of-hospital cardiac arrest; however, other modifiable factors affecting out-of-hospital cardiac arrest ventilation have limited supporting data. Researchers have begun to explore the impact of ventilation in adult out-of-hospital cardiac arrest outcomes, further stressing its importance in cardiac arrest resuscitation management. Capnography and thoracic impedance signals are used to measure ventilation rate, although these strategies have limitations. Existing technology fails to reliably measure real-time clinical ventilation data, thereby limiting the ability to investigate optimal ventilation management. An essential step in advancing cardiac arrest care will be to develop techniques to accurately and reliably measure ventilation parameters. These devices should allow for immediate feedback for out-of-hospital practitioners, in a similar way to chest compression feedback. Once developed, new strategies can be established to guide out-of-hospital personnel on optimal ventilation practices.

Evaluating the levels of knowledge and attitudes of emergency medical technicians and paramedics toward traumatic dental injuries

Objectives

The first aid implemented just after the traumatic dental injury (TDI) is of vital importance. This study aims to evaluate the attitudes of emergency medical technicians (EMTs) and paramedics toward TDI and their levels of knowledge about the issue.

Subjects and Methods

A questionnaire, which comprised 14 questions, was applied to 389 EMTs and paramedics all across Turkey. The questionnaires were sent to the participants through e-mails, and the results were obtained by an online system.

Results

336 out of 389 EMTs and paramedics (86.4%) mentioned that they did not have any training about the TDI issue. On the other hand, among the ones who mentioned that they received this training, 50.9% suggested that the training was not sufficient. It was observed that 63.5% of the participants encountered cases of injuries in oral and dental regions, and in 83% of these cases the only treatment applied was bleeding intervention. About 75.6% of them think that an avulsed tooth cannot be reimplanted.

Conclusion

In conclusion, it was determined that the EMTs and paramedics did not have sufficient and accurate information about the TDI. Lack of knowledge about TDI prevents rapid and accurate intervention to the cases.

Impacts of Emergency Medical Technician Configurations on Outcomes of Patients with Out-of-Hospital Cardiac Arrest

Paramedics can provide advanced life support (ALS) for patients with out-of-hospital cardiac arrest (OHCA). However, the impact of emergency medical technician (EMT) configuration on their outcomes remains debated. A three-year cohort study consisted of non-traumatic OHCA adults transported by ALS teams was retrospectively conducted in Tainan City using an Utstein-style population database. The EMT-paramedic (EMT-P) ratio was defined as the EMT-P proportion out of all on-scene EMTs. Among the 1357 eligible cases, the median (interquartile range) number of on-scene EMTs and the EMT-P ratio were 2 (2–2) persons and 50% (50–100%), respectively. The multivariate analysis identified five independent predictors of sustained return of spontaneous circulation (ROSC): younger adults, witnessed cardiac arrest, prehospital ROSC, prehospital defibrillation, and comorbid diabetes mellitus. After adjustment, every 10% increase in the EMT-P ratio was on average associated with an 8% increased chance (adjusted odds ratio [aOR], 1.08; p < 0.01) of sustained ROSC and a 12% increase change (aOR, 1.12; p = 0.048) of favorable neurologic status at discharge. However, increased number of on-scene EMTs was not linked to better outcomes. For nontraumatic OHCA adults, an increase in the on-scene EMT-P ratio resulted in a higher proportion of improved patient outcomes.

Review article: Prevalence of burnout in paramedics: A systematic review of prevalence studies

Paramedic wellness is an increasing priority within the profession. Burnout has been described as having areas of 'emotional exhaustion, depersonalisation and reduced personal accomplishment'. Prevalence of burnout is unclear, hampering evaluation of protective initiatives. The aim of this systematic review was to identify prevalence and predictors of burnout in paramedic populations. A systematic review was registered via PROSPERO and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO and PsycARTICLES were searched from 2000 to present. Abstract screening and selection of articles was undertaken with good agreement. Quality assessment of included articles used Hoy's validated quality assessment tool, with excellent inter-rater agreement (K = 0.9). Qualitative synthesis of included studies was performed. Each step of the process was performed independently by two authors, with a third arbitrating disputes as required. Five studies met inclusion criteria; two were from the USA, and one each from Australia, South Africa and Israel. Burnout measurement varied; three used Copenhagen Burnout Inventory (CBI), one Maslach's Burnout Inventory (MBI), and one General Burnout Measure (GBM). Prevalence of burnout ranged between 16% and 56%. Higher prevalence was reported in CBI studies (30%, 38% and 56%), while lower prevalence was seen with other tools (MBI 18%, GBM 16%). Included studies were of low to moderate quality. The prevalence of burnout in paramedics varies from 16% to 56%. Existing evidence describing burnout in paramedics is weak; research of good methodological rigour is needed to quantify prevalence of burnout, providing a reliable baseline against which protective interventions could be measured.

Medical Student Perceptions of Emergency Medical Technician Training During the First Year of Medical School

PURPOSE

Medical schools look for ways to provide clinical experiences and skill development in connection with knowledge. One method used is to provide emergency medical technician (EMT) training to medical students; however, limited data are available concerning EMT training in medical education. Therefore, the aim of this study was to review student feedback about the EMT curriculum through multiple iterations of the curriculum.

METHODS

Students completed a voluntary school administered survey upon completion of their first year of medical school. Student responses to statements related to the EMT course and program were analyzed for classes matriculating in academic years 2012-2017. A one-way ANOVA with post hoc Tukey Honestly Significant Difference (HSD) was performed across all years for each survey statement.

RESULTS

Mean response scores to statements related to the EMT course were higher when the EMT course was a standalone course and lower when integrated with biomedical science coursework. Students "strongly agreed" or "agreed" with most statements related to experiences and clinical skill development provided by the EMT program. Response rates ranged between 46-52 (88-100%) for 2012, 40-46 (74-85%) for 2013, 72-79 (88-96%) for 2014, 73-86 (71-83%) for 2015, 47-65 (46-63%) for 2016, 62-82 (59-78%) for 2017.

CONCLUSION

Our data show that first year medical students liked the course design best when the EMT course was a standalone course at the start of the M.D. program while students liked experiences and clinical skill development provided by the EMT program regardless of course design.

Implementation of a Prehospital Patella Dislocation Reduction Protocol

Introduction: Acute patella dislocations account for up to 3% of all knee injuries. Prehospital care of patella dislocation often includes knee immobilization and pain management, but in the wilderness environment patella reductions are often performed by basic life support providers. Given the potential benefits of early reduction, the perceived low risk of harm and precedent with which the procedure can be performed, patella reduction was added to the EMT scope of practice in New York State. Our objective is to characterize the mechanism of patella related injuries and describe the success rate and complications experienced with the addition of a prehospital patella reduction protocol.Methods: This was a retrospective review of a voluntary, preexisting, quality assurance database of cases in which a patella reduction was attempted between October 1, 2016 and June 30, 2018.Results: 90 patients underwent an attempt at patella reduction at one of 52 EMS agencies during the study period. The most common mechanism was a sports-related injury. Patella reduction was successful 83/90 (92.2%). Median pain score was reduced from 10 to 2. There were no reported complications.Conclusion: While a convenience sample, our results provide preliminary evidence that patella reduction can be performed by EMS providers with infrequent complication and offers significant pain relief.

Long-Term PTSD Risks in Emergency Medical Technicians Who Responded to the 2016 Taiwan Earthquake: A Six-Month Observational Follow-Up Study

Although several factors associated with posttraumatic stress disorder (PTSD) in disaster rescue workers were identified in previous studies, the results were inconsistent. This study aimed to explore the prognostic factors of PTSD among disaster rescuers using different screening tools. A 6.4 magnitude earthquake struck southern Taiwan on February 6, 2016. Emergency medical technicians (EMTs) who responded to the earthquake were recruited. The initial survey was conducted one month after the earthquake using a standardized, self-reported, paper-based questionnaire. After six months, we re-evaluated the EMTs using the same questionnaire that was used in the baseline survey. A total of 38 EMT-paramedics were enrolled in the final analysis. Significant differences in PTSD scores at baseline existed between EMTs with and without certain risk factors. The interaction between survey time and risk factors was not significant, but several risk factors correlated with a nonsignificant improvement in the PTSD score after the 6-month follow-up. Perfectionism personality characteristics and several specific field experiences (managing injured patients, managing dead victims, managing dead victims who were pregnant, managing emotionally distraught families, or guilty feelings during the missions) might affect different subdomains of PTSD symptom improvement. Disaster rescuers should be followed up after their missions, regardless of their age, gender, or previous experience with disaster response. EMTs with certain personality characteristics or who are involved in specific field operations should be carefully monitored during and after disaster rescue missions.

Workplace Violence in Asian Emergency Medical Services: A Pilot Study

Workplace violence among Asian emergency medical services (EMS) has rarely been examined. A cross-sectional, mainly descriptive study using a standardized, paper-based, self-reported questionnaire survey was conducted between August and October 2018 among emergency medical technicians (EMTs) in the Tainan City Fire Bureau, Taiwan. A total of 152 EMT-paramedics responded to the questionnaire survey, constituting an overall response rate of 96.2%. The participants were predominantly male (96.1%), college-educated (4-year bachelor’s degree) (49.3%), and middle-aged (35–44 years old) (63.8%). Among them, 113 (74.3%) and 75 (49.3%) participants had experienced verbal and physical assaults at work, respectively. Only 12 (7.9%) participants were familiar with relevant regulations or codes. The assaults predominantly occurred during evening shifts (16:00–24:00) and at the scene of the emergency. The most predominant violence perpetrators included patients, patients’ families, or patients’ friends. Nearly 10% of participants had experienced verbal assaults from hospital personnel. EMTs who encountered workplace violence rarely completed a paper report, filed for a lawsuit, or sought a psychiatric consultation. Fifty-eight (38.2%) and 16 (10.5%) participants were victims of frequent (at least once every 3 months) verbal and physical forms of violence, respectively; however, no statistically significant association was observed in terms of EMT gender, age, working years, education level, or the number of EMS deployments per month. The prevalence of workplace violence among Asian EMS is considerable and is comparable to that in Western countries. Strategies to prevent workplace violence should be tailored to local practice and effectively implemented.

Emergency medical technicians' experiences with unplanned births outside institutions: A qualitative interview study

AIM

To explore emergency medical technicians' experiences with unplanned births outside institutions.

DESIGN

A qualitative interview study.

METHODS

Individual semi-structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material.

RESULTS

Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out-of-hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women.

Iranian pre-hospital emergency care nurses' strategies to manage workplace violence: A descriptive qualitative study

AIM

To explore the experiences of Iranian nurses working in pre-hospital emergency care services and the strategies used to manage of workplace violence.

BACKGROUND

Pre-hospital emergency nurses are subject to workplace violence; however, little research addresses their experiences, particularly related to their strategies in dealing with workplace violence.

METHODS

A descriptive qualitative study that involved nineteen male nurses who were working in pre-hospital services collected data using semi-structured interviews and analysed it using qualitative content analysis.

RESULTS

Data analysis yielded four descriptive categories including no reaction to violence (tolerance and acceptance as common workplace conflicts), situational management (patient and scene management), confrontation (direct and indirect) and escaping the scene. Patient management was the dominant strategy used and had the best outcomes related to both patient and personnel safety.

CONCLUSION

This study showed that pre-hospital nurses use different strategies to manage violence and patient management was a common and useful strategy for managing workplace violence. However, the pre-hospital nurses have little training, insufficient support and are poorly prepared to manage workplace violence.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of context-based guidelines, continuing education, better-equipped ambulances that include medical and defence equipment, as well as better coordination of the police force in ambulance operations, can help to reduce workplace violence.

[A Study of the Self-Assessed Emergency Management Competencies of Emergency Medical Technicians]

BACKGROUND

Emergency medical technicians (EMTs) must be able to assess patient needs for emergency medical services in order to ensure patient safety and optimal prognosis. However, Taiwan currently has no relevant core competency indices or required courses in place for EMTs. The relative inaccessibility of training may seriously compromise the performance of EMTs.

PURPOSE

This study investigated self-assessed emergency management competency and related demographic factors in a sample of EMTs.

METHODS

This cross-sectional survey used a convenience sample of EMTs working at a fire station in eastern Taiwan. Data were collected using a questionnaire including a new emergency management competency self-assessment scale. A total of 272 of the 295 distributed questionnaires were returned (92.2%).

RESULTS

The mean score for emergency management competency was 3.58 points. The highest-scored item was "I know how to use an automated external defibrillator correctly" and the lowest-scored item was "I know how to handle postpartum hemorrhaging (PPT)." The factors that were found to significantly influence self-assessed emergency management competencies included the age, education, EMT qualification, EMT instructor / assistant qualification, and years as an EMT of the respondent and the number of emergency medical tasks handled by their unit per month, average monthly personal workload, and having attended additional emergency medical courses in the previous year.

CONCLUSIONS

Future training for EMTs should focus on improving competencies related to pediatric emergencies, obstetric emergencies, and other low-scoring items using proper instructional materials, strategies, and learning-outcome-assessment mechanisms. This training may be expected to improve the quality and appropriateness of future emergency medical treatment through greater EMT confidence and competence.

The relationship between physical fitness and occupational injury in emergency responders: A systematic review

BACKGROUND

Emergency responders have jobs with physical demands that put them at risk of musculoskeletal injuries.

OBJECTIVES

This paper systematically reviews existing literature examining the relationship between fitness and occupational injury in this group.

METHODS

Comprehensive electronic searches were conducted using key words relating to musculoskeletal injury, fitness, and emergency responders.

RESULTS

Eleven articles included in the review provided limited evidence for the relationship between physical fitness test scores and injury risk. There appears to be a correlation between better aerobic fitness and decreased risk of injury.

CONCLUSIONS

Evidence of the relationship between aspects of physical fitness and occupational injury in emergency responders is extremely limited. More research is required to expand the knowledge in this area and to draw more definitive conclusions.

Research utilization barriers for emergency medical technicians in Saudi Arabia

INTRODUCTION

Translation of research findings into clinical practice has potential to improve health care procedures, increase patient safety, and improve patient outcomes. However, low levels of evidence utilization in clinical practice have been widely reported. Anecdotal evidence suggests that this is also the case for emergency medical technicians (EMTs) in Saudi Arabia. This study aimed to examine the barriers to the utilization of research findings within this cohort.

METHODS

The BARRIERS scale was used to gather data from a convenience sample of EMTs in Saudi Arabia.

RESULTS

The barriers most commonly rated as "great" or "moderate" were "Implications for practice are not made clear", "The relevant literature is not compiled in one place", and "The EMT feels the benefits of changing practice will be minimal". However, when responses were examined at a subscale level, reliability, as measured by Cronbach's α, was suboptimal (range 0.20-0.62).

DISCUSSION

No similar study has been conducted within paramedicine to enable direct comparison of our results; however, the top barriers identified in the present study are also highly rated in some previous studies of nurse cohorts. The low reliability measures of the subscales may demonstrate the importance of context specificity when utilizing this scale and that further research is required to develop a reliable and valid tool for use within this cohort.

CONCLUSION

The top 2 barriers identified indicate that there may be a need for improvement regarding communication of research evidence to Saudi EMTs. For future studies, translation of the BARRIERS scale may be useful. However, as these EMT courses are taught in English, careful consideration of cultural suitability and more subtle interpretation issues could also be appropriate. Once context-specific barriers are identified and examined, they may inform the development of effective strategies to increase the uptake of research evidence into Saudi EMT practice.

Respiratory symptoms among search and rescue workers who responded to the 2016 Taiwan earthquake

OBJECTIVES

High respiratory hazards among search and rescue workers (SRWs) emerged after the World Trade Center attacks on 11 September 2001. There have been limited studies on respiratory symptoms among earthquake SRWs. We investigated the respiratory symptoms and the use of respiratory protective equipment among the SRWs who responded to the 2016 Taiwan earthquake.

METHODS

On 6 February 2016, a 6.4-magnitude earthquake struck southern Taiwan and caused 513 injuries and 117 deaths. During the 9-day field operation, 519 firefighters affiliated with the Tainan City Government Fire Bureau participated in the search and rescue response. A standardised, self-completed questionnaire was used to collect data on demographics, dust exposures, personal protective measures and health outcomes 3 weeks after the earthquake. Descriptive and multivariate analyses adjusting for demographics and exposure variables were performed for new or worsened outcomes.

RESULTS

Of the 519 SRWs, 414 (80%) responded to the questionnaire. Of these SRWs, 153 (37%) reported new or worsened respiratory symptoms, with cough (23%) as the leading symptom, followed by rhinorrhoea or nasal congestion (22%) and chest tightness (6%). More than 90% of the symptoms persisted to the third week after the earthquake. The prevalence of new or worsened respiratory symptoms was significantly higher among SRWs with a higher level of exposure to dust. Prior training in response to respiratory pollutants was only 5%.

CONCLUSIONS

There were significant respiratory hazards among earthquake SRWs. The persistent symptoms and low coverage of training warrant further regular examination and occupational health programmes.

Professionalism among paramedic students: achieving the measure or missing the mark?

BACKGROUND

Professionalism is a pillar of paramedicine. Internationally paramedic curricula emphasize valid assessment of three domains: cognitive, psychomotor, and affective domains (professionalism). Little is reported on competency measures for professionalism specific to paramedicine. Literature suggests that paramedic students, paramedic practitioners, medical directors, and patients believe that professional attributes should have an increased focus.

OBJECTIVE

The objective of this scoping review is to outline valid and reliable assessments that evaluate professional behaviors.

METHOD

This review used Arksey and O'Malley's six-stage scoping methodology. In September 2016, five databases were searched for articles of relevance; these were MEDLINE, Scopus, Google Scholar, PsycINFO/APA, and EMBASE.

RESULTS

A total of 1587 articles were identified after removal of 468 duplicates. Five articles met the inclusion criteria, two of the articles were from the US and three from UK. The studies range from 2004 to 2014. Three different scales were identified but only two were recommended for use. A US-based scale is composed of 11 items and one generic form of professionalism. The UK scale has 77 items and identified 11 factors within 68 items.

CONCLUSIONS

This scoping review serves to describe valid and reliable measures for professionalism among paramedicine by outlining the quantity of instruments evident in the literature. The scoping review aimed to report the scales supporting evidence of validity and reliability. Three scales were identified in a total of five different studies that specifically measured professional attributes in paramedicine. Currently, two scales are available: an evaluation with 11 items and a self-reported questionnaire with 77 items.

Emergency Medical Technician Education in Saudi Arabia: History and Challenges

Alamri Y . Emergency medical technician education in Saudi Arabia: history and challenges. Prehosp Disaster Med. 2017;32(6):699.

Observational Study on Safety of Prehospital BLS CPAP in Dyspnea

Introduction Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival.

METHODS

This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened."

RESULTS

Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO224, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01).

CONCLUSION

The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training. Sahu N , Matthews P , Groner K , Papas MA , Megargel R . Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med. 2017;32(6):610-614.

The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System

Introduction The staffing of ambulances with different levels of Emergency Medical Service (EMS) providers is a difficult decision with evidence being mixed on the benefit of each model. Hypothesis/Problem The objective of this study was to describe a pilot program evaluating alternative staffing on two ambulances utilizing the paramedic-basic (PB) model (staffed with one paramedic and one emergency medical technician[EMT]).

METHODS

This was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (P<.05).

RESULTS

Median on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates.

CONCLUSION

In the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns. Cortez EJ , Panchal AR , Davis JE , Keseg DP . The effect of ambulance staffing models in a metropolitan, fire-based EMS system. Prehosp Disaster Med. 2017;32(2):175-179.

Factors that influence the acceptance of telemetry by emergency medical technicians in ambulances: an application of the extended technology acceptance model

OBJECTIVE

The aim of the study was to verify the effects of patient factors perceived by emergency medical technicians (EMTs) as well as their social and organizational factors on prehospital telemetry use intention based on the technology use intention and elaboration likelihood models.

MATERIALS AND METHODS

This is a retrospective empirical study. Questionnaires were developed on the basis of clinical factors of 72,907 patients assessed by prehospital telemetry from January 1, 2009 to April 30, 2012 by reviewing their prehospital medical care records and in-hospital medical records. Questionnaires regarding the social and organizational factors of EMTs were created on the basis of a literature review. To verify which factors affect the utilization of telemetry, we developed a partial least-squares route model on the basis of each characteristic. In total, 136 EMTs who had experience in using prehospital telemetry were surveyed from April 1 to April 7, 2013. Reliability, validity, hypotheses, and the model goodness of fit of the study tools were tested.

RESULTS

The clinical factors of the patients (path coefficient=-0.12; t=2.38), subjective norm (path coefficient=0.18; t=2.63), and job fit (path coefficient=0.45; t=5.29) positively affected the perceived usefulness (p<0.010). Meanwhile, the clinical factors of the patients (path coefficients=-0.19; t=4.46), subjective norm (path coefficient=0.08; t=1.97), loyalty incentives (path coefficient=-0.17; t=3.83), job fit (path coefficient=-0.32; t=7.06), organizational facilitations (path coefficient=0.08; t=1.99), and technical factors (i.e., usefulness and ease of use) positively affected attitudes (path coefficient=0.10, 0.58; t=2.62, 5.81; p<0.010). Attitudes and perceived usefulness significantly positively affected use intention.

CONCLUSIONS

Factors that influence the use of telemetry by EMTs in ambulances included patients' clinical factors, as well as complex organizational and environmental factors surrounding the EMTs' occupational environments. This suggests that the rapid use intention and dissemination of such systems require EMTs to be supported at both the technical and organizational levels.

Evaluation of a sequential structured educational curriculum for emergency medical technicians in airway management

Background and Aims:

Emergency medical technician (EMT) training programs for certification vary greatly from course to course, but it is necessary that each course at least meets local and national requirements. It is reasonable to expect that EMTs’ performance should improve after a structured educational curriculum. We hypothesized that EMTs’ performance in airway management would improve after a sequential structured educational curriculum involving airway, followed by cardiopulmonary resuscitation (CPR) modules, beyond what is achieved after only the airway module.

Materials and Methods:

To evaluate this, 76 EMTs were assigned to a 2-week airway module with a structured curriculum. This was followed by the 2-week CPR module, and the EMTs were tested before (preCPR test) and after (postCPR test) the CPR modules for improvement in their airway skills. EMTs also completed a questionnaire to evaluate the curriculum.

Results:

PostCPR test mean scores were higher than those of the preCPR test (P < 0.05) except for the bag valve mask domain. EMTs evaluated the curriculum and gave a score of 3.7/5 for perceived achievement of goals of the syllabus for improving their airway skills.

Conclusion:

Thus, a sequential, structured curriculum in airway management followed by CPR, improves EMTs’ performance levels above what they achieved after only the airway module, except for bag valve mask ventilation.

The attrition condition: use of a preparatory course to reduce EMT course attrition and improve performance on North Carolina certification exams

INTRODUCTION

A growing concern in emergency medical services (EMS) education is student attrition. Perchance, there is a population of nonmatriculate students lacking prerequisite academic skills or who are otherwise ill prepared for the unique requirements of the EMS profession. Consequently, addressing these issues could promote academic and occupational preparedness, thereby reducing emergency medical technician (EMT) course attrition.

OBJECTIVE

To measure the impact of a preparatory course designed to address academic and psychosocial skills affecting EMT course completion.

METHODS

We conducted a retrospective analysis of a 24-hour preparatory course using a before-and-after nonexperimental design. The course included the EMT preparatory curriculum, program orientation, work-force-preparedness skills, and an academic skills assessment. All students who were enrolled in an EMT course at a single study site between July 2008 and December 2011 were included. Chi-square analysis was performed on attrition categories defined by CoAEMSP (Academic, Disciplinary, Attendance, Health, Financial, Personal, Never Attended) and state exam categories (Airway, Medical, Trauma, Operations, Pediatrics, Preparatory, Assessment). A logistic regression model calculated the odds ratio (OR) of course completion as a function of preparatory course completion while controlling for demography.

RESULTS

The historical control group consisted of 117 (58.5%) students enrolled prior to implementation of the preparatory course, while the remaining 83 (41.5%) students in the intervention group completed the course. Overall attrition was 115 (57.5%) students, with lower rates observed in the intervention group (32.5 vs. 75.2%, p < 0.01). Among noncompleters, the majority originated from the control groups in attrition categories of Academic (4.8 vs. 39.3%, p < 0.01) and Never Attended (1.2 vs. 14.5%, p < 0.01). Students who took the preparatory course were more likely to achieve course completion (OR = 5.17, p < 0.01). The use of the preparatory course produced a higher first-time test-taker pass rate despite showing little difference in individual categories.

CONCLUSIONS

Students who participated in an EMS preparatory course were 5 times more likely to achieve course completion and perform higher on most portions of the state exam; and the proportion of students that enrolled but never attended an EMT course was reduced. Unlike prior studies, we did not observe a paradoxical increase in other attrition categories after addressing academic preparedness. These findings may prove useful for EMS educators tasked with program planning.

The role of general practitioners in the pre hospital setting, as experienced by emergency medicine technicians: a qualitative study

BACKGROUND

Together with the ambulances staffed with emergency medical technicians (EMTs), general practitioners (GPs) on call are the primary resources for handling emergencies outside hospitals in Norway. The benefit of the GP accompanying the ambulance to pre-hospital calls is a matter of controversy in Norway. The purpose of the present study was to gain better insight into the EMT's experiences with the role of the GPs in the care for critically ill patients in the pre-hospital setting.

METHODS

We conducted four focus group interviews with EMTs at four different ambulance stations in Norway. Three of the stations were located at least 2 hours driving distance from the nearest hospital. The interviews were transcribed and analyzed using systematic text condensation.

RESULTS

The EMTs described increasing confidence in emergency medicine during the last few years. However, they felt the need for GP participation in the ambulance when responding to a critically ill patient. The presence of GPs made the EMTs feel more confident, especially in unclear and difficult cases that did not fit into EMT guidelines. The main contributions of the GPs were described as diagnosis and decision-making. Bringing the physician to the patient shortened transportation time to the hospital and important medication could be started earlier. Several examples of sub-optimal treatment in the absence of the GP were given. The EMTs described discomfort with GPs not responding to the calls. They also experienced GPs responding to calls that did not function in the pre-hospital emergency setting. The EMTs reported a need for professional requirements for GPs taking part in out-of-hours work and mandatory interdisciplinary training on a regular basis.

CONCLUSIONS

EMTs want GPs to be present in challenging pre-hospital emergency settings. The presence of GPs is perceived as improving patient care. However, professional requirements are needed for GPs taking part in out-of-hours work, and the informants suggested a formalized area for training between EMTs and GPs on call.

The relationship between managers' leadership styles and emergency medical technicians' job satisfaction

BACKGROUND/AIMS

Leadership plays a crucial role in many professions, especially in challenging positions such as emergency medical service jobs. The purpose of this study was to explore the relationship between managers' leadership styles and emergency medical technicians' job satisfaction.

METHOD

This is a descriptive and cross-sectional study that was carried out in 2010. The research population included 21 managers and 87 emergency medical technicians working in 23 stations in Isfahan city, Iran. The main tools used for data accumulation were the Multiple Leadership Questionnaire for evaluating leadership styles and the Job Descriptive Index for measuring job satisfaction levels. Also, the Pearson correlation analysis test was used to evaluate the relationship between leadership style and job satisfaction.

RESULTS

Among both managers and technicians, the highest mean score related to the transformational management style, whereas the lowest mean score related to the laissez-faire management style. Moreover, a significant relationship (P<0.01) was found between the transformational and transactional leadership styles and job satisfaction. However, no significant relationship was observed between the laissez-faire management style and job satisfaction.

CONCLUSION

Considering the importance of job satisfaction in medical emergencies, it is recommended that health sector policy makers should provide the groundwork for implementing the transformational leadership style to enhance job satisfaction of the medical emergency staff.