Burnout in firefighter/paramedics (FF/EMT-Ps) is widely believed to exist, but few empirical data support its existence, symptomatology, or intervention. Understanding the extent, nature, and cause of burnout is crucial to improving employee morale and performance.

Ninety-one FF/EMT-Ps employed by Salt Lake County Fire Department.

Three specific hypotheses were tested: 1) FF/EMT-Ps who score high on burnout also will score high on authoritarianism; 2) FF/EMT-Ps who score high on burnout also will score high on inner-directedness; and 3) FF/EMT-Ps who score high on burnout also will score high on sensation seeking.

In this descriptive study, FF/EMT-Ps computed four standardized instruments measuring authoritarianism, burnout, inner-directedness versus other-directedness and sensation seeking.

Firefighters who scored high on burnout also scored high on authoritarianism and on the sensation-seeking subscale of boredom. Burnout did not correlate with the overall sensation-seeking scale or with its other subscales (thrill, experience, and disinhibition), or inner-directedness versus other-directedness.

A focus on control issues needs to be an integral part of programs for decreasing employee burnout among FF/EMT-Ps. Specific components of such programs should include stress management and counseling. In addition, management personnel need to be taught not only to assist direct-service staff, but also to recognize and deal with their own control issues as they affect job performance.

The use of direct medical control (DMC) in the out-of-hospital setting often is beneficial, but has the disadvantage of consuming emergency medical services (EMS) resources.

Uncomplicated, nontrauma, adult patients with chest pain can be treated safely and transported by paramedics without DMC.

Retrospective chart review of all nontrauma, adult patients with chest pain treated in a combined rural and suburban EMS system during a 2-year period (December 1990 through November 1992) was conducted. Before November 1991, DMC was mandatory for all patients with chest pain. Beginning 01 November 1991, if a patient had resolution of pain either spontaneously, with administration of oxygen, or after a single dose of nitroglycerin, DMC was at the discretion of the paramedic. Using the above criteria for inclusion, three study groups were defined: Group 1, before protocol change; Group 2, after protocol change without DMC; and Group 3, after protocol change when physician contact was obtained, but not required. These groups were compared for the following parameters: 1) scene time; 2) time to administration of first dose of nitroglycerin; 3) time interval between measurement of vital signs; 4) oxygen use; 5) intravenous access; and 6) electrocardiographic monitoring. Continuous and categorical variables were analyzed by multivariate and univariate analysis of variance and chi-square tests, respectively.

Of 308 nontrauma, adult patients with chest pain, 71 met inclusion criteria in Group 1, 40 in Group 2, and 34 in Group 3. No statistically significant differences were identified in any of the study parameters.

Adult patients with chest pain who have no other symptoms or complicating conditions can be treated appropriately by paramedics without DMC.

Triage of injured children poses a significant challenge for prehospital-care providers because there is no single trauma triage tool in use that has been developed specifically for children. The pediatric trauma score (PTS) probably is the single most studied and tested trauma triage tool developed solely for the pediatric population, and is an effective predictor of both severity of injury and potential mortality in injured children. However, the pediatric trauma score has been found to be an ineffective prehospital triage tool because it is not “user friendly” for field personnel. As such, the PTS has been modified to generate the more user-friendly ”pediatric trauma triage checklist (PTTC).”

This study retrospectively reviewed 106 prehospital run reports to determine whether the patient met one or more of the criteria in the PTTC. By applying the MacKenzie algorithm to outcome data for each case, it was possible to determine whether the patient should have been sent to a trauma center.

The PTTC demonstrated a sensitivity of 86.2%, a specificity of 41.6%, and an accuracy of 66.0%. The PTTC demonstrate an overtriage rate of 58.3% and an under-triage rate of 13.8%. When compared with a previous study, the PTTC demonstrated a 74 % increase in overtriage. However, the 59% reduction in undertriage is more important.

Use of the PTTC appears to have merit as a pediatric prehospital trauma triage tool but further study is recommended. The PTTC should be tested in a prospective, multiregional study involving a sample size sufficient to reach statistical significance.

Sepsis is a major cause of late morbidity and mortality in the victim of trauma. Currently, there is no method that is clinically practical and accurate for predicting the occurrence of sepsis in trauma victims.

Data were collected on 3,759 motor-vehicle crash victims from 16 hospitals during a 4 1/2 year period. Retrospective analysis was done to examine the relationship of patient and injury factors known within the first 24 hours of admission on the development of sepsis.

Sepsis developed in 154 patients (4.1%) who had a mortality rate of 17.5% Significant early predictors of sepsis included: 1) certain pre-existing conditions; 2) blood transfusion required; 3) seven or more injuries; 4) Glasgow Coma Scale score <10 and hypertension; 5) major blood vessel injury; 6) head trauma; 7) internal injury of the chest or abdomen; 8) spinal-cord injury; and 9) certain fracture types.

These predictors might help target high-risk patients and, thus, promote earlier and more effective treatment for those patients.

As the role of paramedics evolves, evaluation of their ability to accomplish an expanded scope of practice is necessary. The objective of this study was to determine whether specially trained paramedics can monitor and treat patients appropriately during interfacility transports that traditionally have required the use of supplemental, hospital-based personnel.

A paramedic-staffed mobile intensive care unit was developed as a cooperative program between Huron Valley Ambulance and the Washtenaw/Livingston County Medical Control Authority. This prospective observational study involved 111 patients requiring interfacility transport, conveyed by a paramedic-staffed mobile intensive care unit. A change in the Acute Physiologic and Chronic Health Evaluation (APACHE II) score components of mean arterial pressure, heart rate, and respiratory rate at the beginning and end of the transport was used to evaluate the ability of the paramedics to accomplish the transfer appropriately.

APACHE II scares increased in 20 patients, decreased in 16, and were unchanged in 75. The mean value for the change in APACHE score was 0.11 (95% confidence interval: −0.11−0.33).

Specially trained paramedics can monitor and treat patients appropriately during interfacility transfers that traditionally would have required supplementation with additional hospital staff.

Local military conflicts continue in many areas of the world. These conflicts produce multiple casualties to military personnel and civilians. This paper describes one aspect of the medical care required for victims of the civil conflict in the Republic of Georgia.

Interviews with patients and their accompanying persons and abstraction of medical records.

Data were acquired on 108 victims admitted to the Center for Critical Medicine in Tbilisi. Three stages in the care of these victims are described: 1) battlefield and transportation; 2) regional, front-line hospitals; and 3) the Central Hospital. The performance of each stage is described. Distribution of injuries and procedures performed in the third stage of treatment are described and survivors are defined. For illustration, two cases are reviewed in detail.

The results are encouraging. Major problems existed in the treatment and evacuation of the wounded. Furthermore, many of the victims were injured because of their carelessness and lack of experience on the battlefield.

First aid is the initial care of the ill or injured. It aims to preserve and protect life, prevent further injury or deterioration of illness, and help promote recovery. At major public events, there is a large gathering of people, physical spectacles, and equipment within a concentrated area, where organized first-aid care is provided.

To analyze the demand for primary medical care at a public event by identifying the patients and initial symptoms that may predict that demand, and to use such information to improve the efficiency and delivery of medical care.

A questionnaire was completed by St. John Operations Branch personnel after each patient consultation and a retrospective analysis of the data was conducted.

A total of 1,276 questionnaires were returned. Mean patient presentation rate (PPR) was 1.9±0.47 per 1,000 show attendees. This correlated best with the maximum daily temperature (r = 0.715, p <0.02) and show day (r = 0.615, p <0.05). There was poor correlation with daily attendance (r = −0.235, p >0.54). Mean presentation time was 15:13 h. Of those whose gender was recorded, 58.4% were females, and 41.6% were males. The most frequent age group was 13 to 20 years. The nature and number of initial symptoms are listed. Basic first-aid skills were used for 96.7% of symptoms; 2.4% of patients were referred to the hospital.

Temperature and show day significantly contributed to variability of PPR. These factors, together with an estimated PPR and predicted attendance, can be used to forecast demand. Most cases required only basic first-aid skills. Guidelines are suggested for management by nonmedical personnel. A medical officer's role is not reliably defined, but involvement in consultation is suggested.

To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment.

Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence.

A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria.

The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients.

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.

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.

Although 50% to 60% of North American households own pets and many of these pets are considered family members, there is little information on the impact pet ownership on pet-owning families affected by disasters.

This case report describes some of the effects of a tornado on 17 families whose dwellings were destroyed. The setting was a typical urban trailer park.

After a tornado at the Sagamore Village Trailer Park in north central Indiana, 104 families were evacuated. Seventeen (16.3%) of these families owned pets. For 14 families (13.5%), pet ownership had an important impact on the families' recovery from the tornado. Public- and mental-health concerns that arose from pet ownership included failure to evacuate a dangerous site, attempts to re-enter a dangerous site, separation anxiety leading to psychosomatic disturbances, and the need for additional animal care.

In urban disasters, the behaviors of families with a human-animal bond are likely to pose a significant risk to their own and others' health and safety in urban disasters. In this small study of families affected by a tornado, the most prominent public-health concerns were failure to evacuate because of a pet and attempts of re-entry to save a pet; the most common mental-health concerns resulted from separation anxiety from a pet and refusal to accept medical treatment until a pet's well-being can be assured. These are thought to be typical issues that will arise out of the human-animal bond in urban disaster situations and differ considerably from traditional public-health concerns over dog bites, spread of zoonotic diseases, and human food contamination. Medical disaster preparedness planning should consider the substantial effects that the human-animal bond is likely to have on human recovery from large-scale urban disasters.