Motor vehicle injuries are a major public health problem. They are a primary cause of: 1) death and injury in the United States; and 2) result in a substantial loss of productive life. These injuries and fatalities have serious social and economic consequences for the injured individual, their families, and society. This report focuses on the portion of health care expense borne by the public and the tax revenue implications of these injuries and fatalities.

The relationship between motor vehicle injuries and fatalities, health care costs, and income taxes was analyzed for four situations: 1) 1990 baseline; 2) achievement of modest goals for safety improvements; 3) population growth with constant injury and fatality rates; and 4) the effect of higher injury and fatality rates. Total health care costs, publicly funded health care costs, lost income tax revenue, and increased public assistance were estimated at the [U.S.] federal level, and at the state and local level.

Study of these relationships indicate that: 1) the lifetime economic cost of motor vehicle injuries, fatalities, and property damage that occurred in 1990 is $137.5 billion. American taxpayers will pay $11.4 billion of that total to cover publicly funded health care ($3.7 billion), reduced income tax revenue ($6.1 billion), and increased public assistance expenses ($1.6 billion); 2) the lifetime economic cost of alcohol-related, motor vehicle injuries, fatalities, and property damage that occurred in 1990 was $46.1 billion. Of this, the American taxpayer will pay $1.4 billion to cover publicly funded health care and $3.8 billion to cover reduced income tax revenue and increased public assistance; 3) reducing the percentage of the alcohol-related portion of these fatalities from 45% to 43% (1,200 lives saved), and alcohol-related injuries by a proportionate amount, would save American taxpayers $73 million in publicly funded health care and $208 million in income taxes and public assistance; 4) by increasing observed safety-belt usage in passenger cars from 62% to 75%, (1,700 lives saved plus a proportionate reduction in injuries), publicly funded health care costs would be reduced by $180 million, and $328 million would be saved in the combination of increased income tax revenues and reduced public assistance; 5) Further reductions in publicly funded health care, increases in income tax revenues, and reductions in public assistance are possible as a result of reasonable gains in other areas, such as increased safety-belt usage in light trucks, increased usage of motorcycle helmets, increased correct usage of child safety seats, and reducing the number of speeding drivers; 6) if injury and fatality rates remain at the 1992 level, population increases alone would result in 3,300 more fatalities in the year 2000. Economic costs from these fatalities and a proportionate increase in injuries would increase by an estimated $7.4 billion, including a $277 million increase in publicly funded health care costs, and $573 million in reduced income tax revenue and increased public assistance; and 7) if injury and fatality rates increase from the 1992 level, injuries, fatalities, and costs will increase. In one scenario, with 5,800 more fatalities than the population growth scenario, economic costs would increase by $13 billion, including a $350 million increase in publicly funded health care, and an additional $1 billion in taxes to cover lost income tax revenue and increased public assistance.

It is obvious that inaction is a costly alternative and that anticipated population gains will require further reductions in injury and fatality rates just to maintain current injury and fatality rates. Fortunately, countermeasures are to be available that can accomplish this. Lack of vigilance that would result in deterioration of safety levels would be even more costly.

Use of an oxygen-powered demand-valve to ventilate through an endotracheal tube is considered inappropriate due to concern regarding excessive airway pressure.

It was hypothesized that ventilation through an endotracheal tube using a bag-valve (BV) device and the recently modified demand-valve (DV) would produce similar tidal volumes (Vt), minute ventilation (MV), and peak airway pressures (PAP).

This is a prospective, randomized vitro experimental model. Subjects were blinded to volume and pressure gauges. Thirty-nine EMTs (mean age 27 years with mean experience five years) volunteered to ventilate a mechanical test lung through an endotracheal tube for 10 minutes. Each subject was randomized to BV or DV and to either normal (0.1 L/cm H2O) or poor (0.04 L/cm H2O) lung compliance. This DV delivers set flow of 40 L/min at maximum 50±5 cm H2O. Subjects were instructed to use their “usual” technique for an average size adult in respiratory arrest with normal heart rate and blood pressure. The Vt and PAP were recorded for each breat; the MV and maximum PAP (PAP-max) for each minute was noted. Data were analyzed using repeated measures ANOVA and Tuke multiple comparisons with alpha set at 0.05.

Overall average tidal volumes and minute ventilations were acceptable with both ventilalory devices at both normal and poor compliance for the first, fifth, and 10th minute of continuous ventilation. Average airway pressures and peak airway pressures during the first, fifth, and 10th minute of ventilation all were significantly higher with those of the bag-valve than with the use of the demandvalve at both normal and poor compliance.

In this model, ventilation with bag-valve and demand-valve both provided more than adequate Vt and MV; values wer similar except for higher Vt with BV at normal compliance. However, DV yielded significantly lower PAP and PAPmax at both poor and normal compliance. These findings need corrobration in an in vivo model, but suggest that with proper training, demand-valve ventilation through an endotracheal tube may be preferable.

To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area.

Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals.

A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply.

No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.

A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times.

Paramedic trip sheets were reviewed before and after the institution of the QI feedback hop in this interrupted time series design.

The New Castle County, Delaware, Paramedic Program.

All New Castle County paramedics participated in the study.

In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documetation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year.

Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (X2 = 3.04, p <.1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (X2 = 1.40, p <.25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (X2 = 44.24, p <.001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (X2 = 320.5, p <.001).

The use of QI feedback had little effect on psychomotor skills such as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.

Current paramedic training mandates complete immobilization of all patients, symptomatic or not, whose mechanism of injury typically is viewed as conducive to spinal trauma. It is common to observe confrontations between paramedics and walking, asymptomatic accident victims who fail to understand why they should “wear that collar and be strapped to that board.” Immobilized, frustrated patients then may wait for hours in a busy emergency department until a physician declares them to be without spinal injury. Patients frequently refuse treatment and transport.

Algorithms exist for physicians to “clear” the cervical spine (C-spine) without radiography. It was hypothesized that paramedics routinely assess and document these indicators in their patient evaluations.

A retrospective chart review was conducted on 161 patients (Group 1) admitted to a regional medical center with a diagnosis of C-spine injury over a 52-month period. The charts of 225 motor vehicle accident (MVA) victims (Group 2) transported by ambulance to the emergency department over a five-month period then were studied. Indicators for C-spine injury documented by emergency medical service (EMS) personnel were abstracted.

All patients underwent mental status assessment and full spinal immobilization (neck and back) by EMS crews prior to transport to the hospital. Two or more indicators of possible C-spine injury were documented on each prehospital care report (PCR).

Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings.

Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial.

This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma.

The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma.

The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway—CSF—breathing spontaneously, stable vital signs; 2) Urgent airway—CSF—breathing spontaneously, unstable vital signs; and 3) Emergent airway—CSF—apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures.

Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81 %, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%.

The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation.

The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.

To identify risk factors for adverse events that occur during interfacility transfers by advanced life support (ALS).

A four-year, retrospective, case series.

Three ALS units in a rural/suburban emergency medical services (EMS) system.

351 transports to or from twelve acute care facilities; two patients records could not be located.

Patients were classified by illness/injury, transporting staff, and ongoing therapy; these were correlated with frequency of ALS intervention and patient deterioration.

During the study period, the number of transfers as a percentage of total calls (1.1%–5.2%) rose consistently. There were 11 illness/injury categories; the largest was cardiac (44%, 154 patients). Hospital staff accompanied the patient in 15% (52). Advanced life support (ALS) therapy was required in 4.9% (17): one monitored cardiac arrest was defibrillated successfully, 13 patients required unanticipated medication therapy, and three were noted to have clinical deterioration en route. The upper 95% confidence limit for cardiac arrest is 12.9/1,000 transfers or 20.8/1,000 hours. Patient deterioration and the need for ALS intervention were associated with the presence of medication infusions (p <.O5), but not with hospital staff (p >.40).

Interfacility transfers of a heterogeneous group of patients in this series involve a low risk of cardiac arrest. Patients with medication infusions are at higher risk of deterioration and more frequently require ALS intervention en route. The presence of hospital staff had no measurable effect. These findings have implications for the development of ALS transfer protocols.

To assess the accuracy of paramedic estimates of adult body weights in cardiac arrest cases.

Paramedics could accurately estimate the weights of out-of-hospital cardiac arrest patients.

Retrospective data analysis of a 15-month, multicenter study involving nontraumatic out-of-hospital cardiac arrest patients. Paramedic estimates of body weights were compared to weights measured in the hospital. Patients were included in the analysis only if both a paramedic weight and a measured in-hospital weight were recorded.

Six urban emergency medical services systems.

The study population included adults with return of spontaneous circulation who subsequently were admitted to the hospital.

Pearson correlation analysis of paramedic-estimated weights and measured weights.

Among the 133 study patients, the correlation coefficient (R) for paramedic estimates and the actual measured weight was 0.93. Paramedic estimates of weight were within 10% of the measured weights in 74% of the patients, and within 20% of measured weights in 93% of the patients.

Paramedic weight estimates correlated well with measured weights.

A study was done with EMS personnel to determine the ease of use and accetance of a saline lock (SL), intermittent infusion device in place of traditional intravenous tubing and fluid bags for prehospital intravenous (IV) maintenance.

Saline lock, intermittent infusion device use in specific clinical scenaios is easier, less expensive, and as effective traditional TV tubing and fluid bags. The emergency medical technician-paramedic (EMT-P) would accept the implementation of saline locks in the emergency medical servics (EMS) system.

This was a prospective, non-blinded study with the EMS providers under the medical command of a suburban community hospital's emergency department. Patients were included if prophylactic IV access or medication administration was required by clinical protocols. Excluded from the study were those patients requiring IV access for fluid infusion, constant drug infusion, cardiac arrests, or transport to another hospital's emergency department (ED). Intravenous access was achieved with the usual catheter over needle cannulation techniques. The device (Interlin Injection Site SL) was attached to the hub of the IV cannula and flushed with 2 cc of 0.9% saline from prefilled carpujects.

There were completed questionnaires for 79 successful SL initiated in 98 attempts of IV access on 80 patients over a four-month period. When compared to traditional IV fluid bags, SL were judged by the paramedics to be less time-consuming to initiate and maintain (55 of 79 or 70%), easier to use (51 of 79 or 65 %) and facilitated patient transportation (73 of 79 or 92%). Medications were administered according to protocol or command dirtion in the prehospital setting through 20 (25%) SL. Intravenous access was maintained by 52 of 79 SL (65 %), and seven (9%) SL were converted to fluid infusions in the prehospital setting after contact with the medical command physician. In the ED, two (3%) SL were judged by nurses to be nonpatent and 17 (22 %) were converted to maintenance fluid infusions. Systemwide use of SL was favored by 73 of 79 (92.4%) EMS providers. Each device and 2 ml 0.9% saline flush carpuject cost [U.S.]$1.62 versus the cost of IV tubing and a 250 cc bag of lactated Ringer's at $2.11, resulting in a cost savings of 23.2%.

The saline lock, intermittent infusion device is an effective method of maintaining prehospital IV access. When compared to traditional IV fluid bags, EMT-Ps judged the device to be easier and less time-consuming to initiate, and facilitated patient transportation. A cost savings was realized when SL usage was compared to traditional IV fluid bag infusion. Systemwide implementation of the saline lock was desired.