To determine characteristics of continuing education programs for paramedics in large metropolitan areas, and to make recommendations for changes in the Chicago Emergency Medical Services (EMS) system.

A survey of 95 metropolitan areas from each state in the United States.

EMS medical directors, coordinators, and administrators.

The survey population included 56 respondents. Within this group, 23% were from areas of 1 million people or more, 61% in areas with populations of 100,000 to 1 million and 16% from areas populated by < 100,000 people. Several system types were represented in the survey. In the systems surveyed, 98% mandate didactic continuing education requirements. Clinical continuing education was required by 34% of the systems. Ten systems (18%) awarded continuing education hours for documented in-field experience. This method did not have a specific structure by the majority of users. Both written and skills testing were used by most EMS systems to evaluate paramedic competency. No statistically significant differences (p >0.05) could be found among population subgroups or EMS system types when evaluating the use of these various methods.

EMS systems primarily use didactic sessions to meet their continuing education requirements. Nearly half of the systems requiring clinical continuing education use in-field credit to fulfill these requirements. In-field credit systems are poorly developed to date. This mechanism may be an effective alternative to usual clinical experiences for paramedics and deserves further investigation.

The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult.

This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET-tube placement using the EDD in five swine in respiratory arrest. The ET tube was placed in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest.

There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present.

The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device.

While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care.

Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews.

Data for the two most common advanced life support calls in this system—seizures and chest pains—were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calk. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls.

One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0±4.2 minutes for three-person crews and 19.4±8.3 minutes for two-person crews (p <0.001). Mean on-scene time for patients with chest pain was 13.6±4.9 minutes for three-person crews, and 15.4±3.2 minutes for two-person crews assisted by fire department personnel (p >0.05).

Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer onscene times than three-person EMS crews.

To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America.

Cross-sectional, epidemiological survey.

Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting.

The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided.

A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations.

The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education.

To compare the efficacy of high-dose epinephrine (HDE) with standard-dose epinephrine (SDE) in the management of cardiac arrest in adults in the prehospital setting.

The use of HDE will improve the outcome of adult patients in cardiac arrest.

In a general population of 700,000 persons, in a mixed geographical area of 2,200 square miles, a 12-month retrospective study of SDE and a 12-month prospective trial of HDE were conducted involving adult patients in cardiac arrest in the prehospital setting. Treatment was provided by paramedic-level clinicians. In the control group, patients were treated according to existing American Heart Association cardiac resuscitation guidelines using SDE (defined as 1.0 mg boluses to a maximum dose of 4 mg). In the test group, the same guidelines were revised to use HDE (defined as a rapid sequence of 5, 10, and 15 mg boluses to a total dose of 30 mg).

The control group included 594 patients; the test group consisted of 580 patients. The overall survival rate to hospital admission in the control group was 14.5% (84 patients) and in the test group 15.3% (89 patients). The survival rate to hospital discharge in the control group was 4.9% (29 patients) versus 4.8% (28 patients) in the test group. For patients whose initial rhythms were ventricular fibrillation, survival to admission in the control group was 20.4% (39 patients) versus 24.4% (43 patients) in the test group. Survival to discharge for patients with ventricular fibrillation in the control group was 8.9% (17 patients) versus 10.8% (19 patients) in the test group.

There was no statistically significant difference in overall rate of survival to hospital admission or discharge between patients treated with SDE and those treated with HDE, regardless of the initial rhythm.

To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting.

Prospective convenience sample in a prehospital setting.

Intubated adult patients.

The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient.

Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%).

This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes.