RESUMEN
BACKGROUND: In contrast to the widespread practice in life-threatening emergencies, delegation of medical pain therapy to paramedics by the medical director of Emergency Medical Services, EMS, are still the exception in Germany. This is due to the fact that in non-life-threatening situations, the expected benefit and potential side effects of drug therapy have to be carefully weighed. In addition, in Germany federal law generally restricts the administration of opiates to physicians. METHODS: In 2011 the medical directors of EMS in the German state of Rhineland- Palatinate (4 million inhabitants) developed and implemented a standard operating procedure (SOP) for paramedics related to the prehospital parenteral administration of paracetamol for patients with isolated limb trauma. After a 2 h training session and examination, paramedics were authorized to administer 1 g of paracetamol to patients with a pain score > 5 points on an 11-point numerical rating scale (NRS). For purposes of quality management, every administration of paracetamol had to be prospectively documented on a specific electronic mission form. RESULTS: A total of 416 mission forms could be analyzed. After administration of paracetamol the median NRS score decreased from 8 points (interquartile range: 6; 8) to 4 points (interquartile range: 3; 7). In 51.2 % of the patients the pain intensity was reduced by at least 3 NRS points and in 50.5 % of the patients the NRS was less than 5 points after treatment. The extent of pain reduction was positively correlated with the initial NRS value (r = 0.31, p < 0.0001). No serious side effects were noted. The percentage of patients with an initial heart rate > 100/min declined from 14.6 % to 5.2 % after the administration of paracetamol (p < 0.0001), 18.7 % of the patients received paracetamol for trauma not related to the extremities and 7 % of the patients for nontraumatic pain. An emergency physician was involved in 50 % of the EMS missions and 98.6 % of the patients were transported to a hospital for further diagnostics and treatment. CONCLUSION: The prehospital intravenous administration of paracetamol by paramedics to patients with limb trauma is simple, safe and in 50 % of the patients effective in achieving a NRS value < 5; however, further improvements in prehospital pain therapy initiated by paramedics are desirable, especially in patients with an initial NRS value > 7.
RESUMEN
BACKGROUND: A growing number of reports have been published in Germany related to problems with the operational readiness of mobile emergency physician services, although no systematic analyses have yet been presented. However, such investigations form the prerequisite for the deployment of countermeasures. METHODS: Rhineland-Palatinate (4,060,000 inhabitants, 7,753 mi(2)) is a typical territorial state in the southwest of Germany with extensive wooded areas covering 42% of the state and only few metropolitan areas. These basic conditions represent a challenge to the provision of state-wide emergency medical services (EMS). On behalf of the Ministry of the Interior a web-based platform for the collation, display and analysis of the operational readiness of all 68 ground-based physician-staffed emergency units within the state was developed. Of these units 61 are affiliated to hospitals and 7 units to medical practices and 89,000 emergency missions are carried out annually. RESULTS: Within the study period (April 2009-March 2010) 56 of the 68 units (82.4%) reported 1 or more periods of unavailability of operational readiness. In total 2,613 periods of temporary unavailability were documented with a mean duration of 8.9 h. The mean unavailability of operational readiness was 3.9% for the whole state, 6.2% for the northern and 1.6% for the southern EMS districts. In 7 of the units (10.3%) the degree of unavailability exceeded 5% and in 8 units (11.7%) it exceeded 10%. Two thirds of all suspended services were the result of shortages of emergency physicians, with considerably higher deficits at bases affiliated with hospitals of lower levels of care or in rural regions. CONCLUSIONS: This tool enables the large-scale collation and analysis of the operational readiness of physician-based ambulance services. Currently the state does not suffer from a general lack of emergency physicians. However, rural areas as well as bases affiliated with small hospitals show a considerable deficit in operational readiness caused by a shortage of staff. These deficits may be partially compensated by optimized planning and disposition within rescue coordination centers. Moreover, they call for corrective actions in the light of health care politics. In addition, analyses of other elements of EMS (i.e. rescue helicopters) should be undertaken.