Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs.

To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues.

A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993.

Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings.

Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.

Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers.

Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included: trauma, intoxication, drowning, shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records.

Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the “alert, verbal, painful, unresponsive” scale (ALS vs BLS) were: “verbal” (40% vs 51%), “painful” (23% vs 23%), and “unresponsive” (37% vs 25%). The mean value for scene time was 15±6 minutes for ALS versus 10±4 minutes for BLS (p <0.001). On arrival in the emergency department, the LOC of 72 (64 %) ALS patients and 58 (64%) BLS patients had improved to “alert.” The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principal final diagnoses were seizure (27% ALS vs 38% BLS), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS provider had significantly shorter emergency department treatment times than did those transported by BLS providers (160±62 minutes ALS vs 229±67 minutes BLS [p <0.005]).

Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients.

Blood pressure (BP) in the out-of-hospital setting is one of the most important diagnostic tools used by emergency medical services (EMS) providers. Conventional methods of palpation and auscultation can be time consuming, and the measurements often are inaccurate because of the adverse working conditions encountered. Pulse oximetry waveform systolic blood pressure (POWSBP) measurement has been used successfully in emergency departments to monitor BP. The objective of this study was to compare the accuracy of field POWSBP measurements obtained by noninvasive electronic BP measurement (NIBPM), auscultation, and palpation in the out-of-hospital environment.

Blood pressure measurements used for this study were obtained by POWSBP, NIBPM (PROPAQ model 102; Protocol Systems, Beaverton, Oregon USA), auscultation, and palpation on patients in moving ambulances. Measurement of POWSBP was accomplished by observing the return of the waveform on the pulse oximeter at the time of cuff deflation. The order in which the readings were obtained as well as the arm chosen for measurement were randomized.

Paramedics and emergency medical technicians in an urban, inner-city emergency medical services (EMS) system.

Bloopressure measurements were sampled from 69 patients. Regression analysis identified significant correlation between POWSBP and the four methods utilized, with r = 0.92 for NIPBM, r = 0.95 for auscultation, and r = 0.97 for palpation, all significant at p<0.0001.

The use of POWSBP measurement is a fast, easy, and accurate technique with which to measure systolic BP in the field. It may have special importance for noisy environments and moving vehicles in which conventional methods of auscultation or palpation may be difficult.

To determine core temperature (Tc) elevations in hazardous materials (HazMat) technicians wearing level-A fully encapsulated, chemically resistive suits (FECRSs) during training scenarios.

Cross-sectional, observational feasibility study with Institutional Review Board approval.

HazMat training scenarios held during the summer of 1994. Weather conditions included both rainy and sunny days, with a mean ambient temperature of 75.8°F(24.3°C) (range 69–83° F [20.6–28.3°C).

Nine male firefighters participating in training scenarios in the Midwestern United States.

Each volunteer swallowed a capsule containing a Tc sensor developed by the National Aeronautics and Space Administration. The capsule continuously monitored Tc and stored data in an ambulatory recorder worn under the level-A FECRS during training.

Mean age of the volunteers was 34 years, mean weight was 92.6 kg, and average baseline Tc was 36.7°C (97.1°F) (range 35.3–38.2°C [95.5–100°F]). Time in the FECRS averaged 25.4 minutes (range 14–35 minutes). All subjects demonstrated increased Tc while in the suit; the mean Tc increase was 0.8°C (1.4°F) (range 0.2–1.3°C [0.4–2.3°F]). The Tc continued to increase during wet decontamination procedures and after suit removal. Mean heat storage values (ΔTcx LBMx 3.47 kJ) were calculated, and found to be moderately elevated to 3.6 kJ/kg (range 2.1–4.6 kJ/kg).

These observations support the validity and significance of implementing prophylactic measures for firefighters using protective clothing. Simple protective measures include enforced time limitations, hydration, and efforts to minimize heat buildup by avoiding both direct sunlight and unnecessary time encapsulated in the suit.

Prehospital personnel, including law enforcement officers, paramedics, and fire-fighters, may be exposed to the human immunodeficiency virus (HIV) while working. This study of prehospital personnel sought to determine: 1) their knowledge of the acquired immune syndrome (AIDS) and HIV transmission; 2) the extent of AIDS training received; 3) self-assessment of risk for HIV infection; and 4) precautions adopted to reduce occupational risk of exposure to HIV.

A survey was administered to prehospital personnel in a large Southern California jurisdiction. The response rate was 41% (n = 1,756) in 10 city and county departments where respondents were employed. Law enforcement officers (44%), firefighters (44%), and paramedics (12%) comprised the sample.

Respondents had accurate knowledge about AIDS, but incorrect perceptions about HIV transmission. A minority believed that HIV could be contracted from casual contact. Training relating to AIDS was not frequent. Preventive practices were infrequent in the work setting, with precautions used less than 50% of the time on eight of 10 measures. One-third of these prehospital personnel assessed their risk for HIV infection as medium to high, largely attributable to fear of occupational exposure.

Improved educational programs regarding HIV/AIDS are needed for prehospital personnel to increase the use of preventive occupational practices in the field.