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BACKGROUND: Time indices are key elements in prehospital medical emergencies. The number of calls to Emergency Medical Services (EMS) and the number of missions they have undertaken have been impacted by the COVID-19 epidemic. OBJECTIVES: This study's goal was to evaluate prehospital EMS time indices at the apex of the COVID-19 outbreak. METHODS: Data were extracted retrospectively from the Asayar Automation System, which records details on all emergency medical calls resulting in patient transport. The study period was from March 2018 to March 2021, covering the pre-COVID period and the first through sixth peaks of the pandemic in Iran. Standardized data extraction procedures were used to minimize bias in this retrospective review. RESULTS: In this study, most transport missions occurred during the fifth peak (n = 2811). In addition, the most missions were related to the age group above 60 years (31.1%), and the highest rate of patient transport (65.9%) was observed in male patients. Traumatic events, cardiac emergencies, impaired consciousness, and psychiatric disorders were, respectively, the main causes of patient transport. Moreover, a significant difference was observed between time indices of various COVID-19 peaks (p < 0.001). CONCLUSIONS: Even though the structure of Iran's emergency system is based on the American-Anglo model, and rapid patient transfers to medical facilities are prioritized, the COVID-19 epidemic resulted in increased calls and missions and affected time indices. Therefore, it is suggested that the method and type of service provision be modified during similar crises.

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This is a case series of three patients who presented to the medical facilities at Burning Man, an annual week-long gathering in the Black Rock Desert of Nevada, for recreational grayanotoxin ingestion. Grayanotoxin, also known as "mad honey," caused the patients to present with varying degrees of dizziness, nausea, vomiting, and diarrhea based on the quantity ingested. Vital signs showed significant bradycardia and hypotension and were successfully treated with atropine and intravenous fluids. Patients were later discharged after a period of observation and resolution of symptoms.

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Background: This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in "intermediate density" areas, such as Denmark, by bringing them directly to the comprehensive stroke center. Methods: We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: "drip and ship" with and without helicopter and "bypass" with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality. Results: The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261).A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%. Conclusions: Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.

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Background and Purpose: Acute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania. Methods: We conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas. Results: In total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs. 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs. 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1-2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1-2.5]). The improvement of PPV was observed in urban EMS (84.9% vs. 71.2%, p = 0.003), but not in the suburban group (75.0% vs. 72.6%, p = 0.621). Conclusions: The interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.

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Background: Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT. Methods: We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014-2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression. Results: We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9-18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 min (IQR: 137-190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted ß [95% CI]: -27.6 min [-51.2 to -3.9]). No clinical characteristics were associated with call-to-CSC time. Conclusion: In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 h. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.

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Background: In Greater Manchester (GM), prehospital clinicians use the Face Arm Speech Test (FAST) to identify suspected stroke patients alongside pathway exclusions. Within the centralized stroke service, patients with a suspected stroke are taken directly to a Hyper Acute Stroke Unit (HASU), often bypassing their local emergency department (ED). However, many of these patients are experiencing an illness that looks like a stroke but is not a stroke. The data collected in the prehospital setting is rarely used in research yet could give valuable insights into the performance of the pathway. Aim: To evaluate the presenting symptoms and final diagnoses of prehospital suspected strokes and to evaluate the adherence of prehospital stroke pathway exclusions. Methods: We analyzed data from all patients brought in by ambulance and admitted on the stroke pathway between 01/09/15 and 28/02/17. Patient demographics and all data recorded in the prehospital setting were evaluated to identify differences in stroke, TIA, and mimic patients. Pathway adherence was assessed according to whether the patient was local or out-of-area (OOA) and bypassed their local ED. Results: A total of 4,216 suspected strokes were identified: 2,213 (52.5%) had a final diagnosis of stroke, 492 (11.7%) experienced a transient ischemic attack (TIA), and 1,511 (35.8%) were stroke mimics. There were 714 (16.9%) patients that were identified as having at least one pathway exclusion or were FAST negative, of which 270 (37.8%) experienced a stroke. The proportion of strokes was significantly lower in those with a pathway exclusion (41.8 vs. 53.5%; p < 0.001) and the proportion of breaches tended to be comparable or higher in the local population. Discussion: There are high volumes of stroke mimics but identified differences indicate there is an opportunity to better utilize prehospital data. Ambulance clinicians were able to correctly overrule FAST negative results and the volume of these suggest that FAST alone may be too restrictive.

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Stroke identification is a key step in acute ischemic stroke management. Our objectives were to prospectively examine the agreement between prehospital and hospital Modified National Institutes of Health Stroke Scale (mNIHSS) assessments as well as assess the prehospital performance characteristics of the mNIHSS for identification of large vessel occlusion strokes. Method: In this prospective cohort study conducted over a 20-month period (11/2016-6/2018), we trained 40 prehospital providers (paramedics) in Emergency Neurological Life Support (ENLS) curriculum and in mNIHSS. English-speaking patients aged 18 and above transported for an acute neurological deficit were included. Using unique identifiers, we linked the prehospital assessment records to the hospital record. We calculated the agreement between prehospital and hospital mNIHSS scores using the Bland-Altman analysis and the sensitivity and specificity of the prehospital mNIHSS. Results: Of the 31 patients, the mean difference (prehospital mNIHSS-hospital mNIHSS) was 2.4, 95% limits of agreement (-5.2 to 10.0); 10 patients (32%) met our a priori imaging definition of large vessel occlusion and the sensitivity of mNIHSS ≥ 8 was 6/10 or 0.60 (95% CI: 0.26-0.88) and the specificity was 13/21 or 0.62 (95% CI: 0.38-0.82), respectively. Conclusions: We were able to train prehospital providers to use the prehospital mNIHSS. Prehospital and hospital mNIHSS had a reasonable level of agreement and and the scale was able to predict large vessel occlusions with moderate sensitivity.

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OBJECTIVES: In traumatically injured patients, excessive blood loss necessitating the transfusion of red blood cell (RBC) units is common. Indicators of early RBC transfusion in the pre-hospital setting are needed. This study aims to evaluate the association between hypothermia (<36°C) and transfusion risk within the first 24 hours after arrival to hospital for a traumatic injury. METHODS: We completed an audit of all traumatically injured patients who had emergent surgery at a single tertiary care center between 2010 and 2014. Using multivariable logistic regression analysis, we evaluated the association between pre-hospital hypothermia and transfusion of ≥1 unit of RBC within 24 hours of arrival to the trauma bay. RESULTS: Of the 703 patients included to evaluate the association between hypothermia and RBC transfusion, 203 patients (29%) required a transfusion within 24 hours. After controlling for important confounding variables, including age, sex, coagulopathy (platelets and INR), hemoglobin, and vital signs (blood pressure and heart rate), hypothermia was associated with a 68% increased odds of transfusion in multivariable analysis (OR: 1.68; 95% CI: 1.11-2.56). CONCLUSIONS: Hypothermia is strongly associated with RBC transfusion in a cohort of trauma patients requiring emergent surgery. This finding highlights the importance of early measures of temperature after traumatic injury and the need for intervention trials to determine if strategies to mitigate the risk of hypothermia will decrease the risk of transfusion and other morbidities.

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The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.

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OBJECTIVES: There has been limited evaluation of handover from emergency medical services (EMS) to the trauma team. We sought to characterize these handover practices to identify areas of improvement and determine if handover standardization might be beneficial for trauma team performance. METHODS: Data were prospectively collected over a nine-week period by a trained observer at a Canadian level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders and EMS according to a bidirectional Likert scale. RESULTS: 79 formal verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Of all questions asked, 35% were questioning previously given information. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking. There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders. CONCLUSIONS: We have identified the need to standardize handover due to poor information content, a lack of structure and active listening, information repetition, and discordant expectations between team members. These data will guide the development of a co-constructed framework integrating the perspectives of all team members.

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INTRODUCTION: Four percent of ST-elevation myocardial infarctions (STEMIs) are complicated by an out-of-hospital cardiac arrest (OHCA). Research has shown that shorter time to initial defibrillation in patients with ventricular fibrillation/tachycardia (VF/VT) arrests increases favourable neurologic survival. The purpose of this study is to determine whether routine application of defibrillation pads in patients with prehospital STEMI decreases the time to initial defibrillation in those who suffer OHCA. METHODS: This was a health records review for adult patients diagnosed with STEMI in the prehospital setting from January 2012 to July 2016. Patients were included if they had a 12 lead ECG indicative of STEMI and subsequently suffered VF/VT OHCA while in paramedic care. This study was designed to evaluate the effects of the "pads-on" protocol in a pre (Jan 2012-May 2014) /post implementation fashion (Jun 2014- Jul 2016). Records were reviewed for relevant patient and event features. T-test was used to measure the difference between mean times to defibrillation. RESULTS: 446 patients were diagnosed with prehospital STEMI. 11 suffered OHCA while in paramedic care. The mean (SD) age was 66.0 (9.3) and 55% were female. In the 4 patients treated with the "pads-on" protocol, the mean time to initial defibrillation was 17.7 seconds, compared to 72.7 seconds in patients who had pads applied following arrest (Δ 55.0 sec [95% CI 22.7-87.2 s]). CONCLUSION: Routine application of defibrillation pads in STEMI patients who suffer OHCA decreases time to initial defibrillation, which has previously been demonstrated to increase favourable neurologic survival.

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OBJECTIVES: Extant research has established an empirical relationship between fatigue and safety-related outcomes. It is not clear if these findings are relevant to Canadian paramedicine. The purpose of this study was to determine if fatigue and shiftwork variables were related to safety outcomes in Canadian paramedics. METHODS: A survey was conducted with ten paramedic services in Ontario with a 40.5% response rate (n = 717). Respondents reported levels of fatigue, safety outcomes (injury, safety compromising behaviours, and medical errors/adverse events), work patterns (types of shifts, hours worked weekly) and demographic characteristics. Univariate and logistic regression analyses were used to assess for significant differences. RESULTS: In this sample, 55% of paramedics reported being fatigued at work. Fatigued paramedics were over twice as likely to report injuries, three times as likely to report safety compromising behaviors, and 1.5 times more likely to report errors/adverse outcomes. When controlling for fatigue, shift length variables did not consistently influence safety outcomes. CONCLUSION: These results create preliminary evidence of a relationship between fatigue and safety outcomes in Canadian paramedicine. While more research is needed, these findings point to the influence fatigue has on safety outcomes and provide an indication that fatigue mitigation efforts may be worthwhile.

OBJECTIF: D'après les travaux de recherche, il existe une relation empirique entre la fatigue et les résultats liés à la sécurité. Toutefois, on ne sait pas si les constatations s'appliquent à la paramédecine au Canada. L'étude avait donc pour but de déterminer si la fatigue et les variables relatives au travail par postes avaient une incidence sur les résultats liés à la sécurité chez les ambulanciers paramédicaux au Canada. MÉTHODE: Une enquête a été menée dans 10 services paramédicaux, en Ontario, et le taux de réponse a atteint 40,5% (n = 717). Les participants devaient faire état du degré de fatigue, de résultats liés à la sécurité (blessure, comportements mettant en péril la sécurité, erreurs médicales et effets indésirables), du régime de travail (type de roulement, nombre d'heures de travail par semaine) et de données démographiques. Des analyses de régression logistique et unidimensionnelle ont été effectuées afin de mettre en évidence des écarts importants. RÉSULTATS: Dans l'échantillon étudié, 55% des ambulanciers paramédicaux ont déclaré ressentir de la fatigue au travail. Ceux-ci étaient plus de deux fois susceptibles de subir des blessures, trois fois plus susceptibles d'avoir des comportements mettant en péril la sécurité et une fois et demie plus susceptibles de déclarer des erreurs ou des effets indésirables. Par ailleurs, lorsqu'on tenait compte de la fatigue, les variables relatives à la durée des postes de travail n'avaient pas la même incidence sur les résultats liés à la sécurité. CONCLUSION: Les résultats fournissent des données préliminaires sur l'existence d'une relation entre la fatigue et les résultats liés à la sécurité en paramédecine au Canada. Si le sujet demande à être approfondi, les constations font déjà ressortir l'incidence de la fatigue sur les résultats liés à la sécurité ainsi que la pertinence de trouver des moyens d'atténuation de la fatigue.

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OBJECTIVES: With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients. METHODS: We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage). RESULTS: We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25-60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2-7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%). CONCLUSIONS: Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.

OBJECTIF: Compte tenu de la régionalisation des soins en traumatologie, la durée des transports pour raison médicale peut être prolongée, ce qui oblige les ambulanciers paramédicaux à traiter les symptômes et à donner des soins. L'étude visait donc à évaluer le soulagement de la douleur durant le transport aérien des polytraumatisés. MÉTHODE: L'étude consistait en un examen de dossiers électroniques d'ambulanciers paramédicaux, provenant d'une agence provinciale de transport de blessés en phase critique, sur une période de 12 mois. Les critères d'inclusion comprenaient un âge ≥ 18 ans et le transport aérien vers un centre de traumatologie; et les critères d'exclusion, un score < 14 sur l'échelle de Glasgow, l'intubation ou l'accompagnement d'un médecin ou d'une infirmière. La collecte d'éléments factuels se composait de données démographiques, de renseignements sur les blessures et de paramètres relatifs au transport. Les résultats étudiés comprenaient l'évaluation de la douleur sur une échelle numérique de 11 points, les modes d'administration des analgésiques et les événements indésirables liés à l'analgésie. Les résultats sont exprimés sous forme de moyenne ± l'écart type [fourchette], (pourcentage). RÉSULTATS: Ont été retenus dans l'étude 372 patients : âge : 47,0 ans; hommes : 262; contusions : 361. La durée de transport était de 82,4 ± 46,3 minutes. Parmi les 232 patients (62,4%) qui ont reçu des analgésiques, la douleur au départ s'élevait à 5,9 ± 2,5 sur l'échelle numérique. Le médicament le plus souvent administré était le fentanyl, à raison de 44,3 µg [25­60]. Une diminution de l'intensité de la douleur de 1,1 [-2­7] sur l'échelle numérique a été enregistrée après la première dose d'analgésique; par la suite, 171 patients (73,7%) ont reçu 2,4 doses additionnelles [1­18]. De leur côté, 44 patients (23,4%) n'ont noté aucun changement sur l'échelle numérique après la première dose d'analgésique, et les doses suivantes n'ont rien changé à l'évaluation de la douleur chez plus de 65% des patients. Enfin, 43 événements indésirables ont été enregistrés, dont le plus fréquent était les nausées (39,5%). CONCLUSIONS: Les doses initiales et subséquentes d'analgésiques ont eu peu d'effets sur le soulagement de la douleur, selon l'évaluation faite sur l'échelle numérique, probablement en raison d'un dosage inadéquat, du moins en partie. Aussi faudrait-il mener des études sur les obstacles à l'administration d'une analgésie appropriée et sur la manière de les vaincre.

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BACKGROUND: Little is known about the associations between the duration of prehospital cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) and outcomes among paediatric patients with out-of-hospital cardiac arrests (OHCAs). We investigated these associations and the optimal prehospital EMS CPR duration by the location of arrests. METHODS: We included paediatric patients aged 0-17 years with OHCAs before EMS arrival who were transported to medical institutions after resuscitation by bystanders or EMS personnel. We excluded paediatric OHCA patients for whom CPR was not performed, who had cardiac arrest after EMS arrival, whose EMS CPR duration were < 0 min or ≥120 min and who had cardiac arrest in healthcare facilities. Prehospital EMS CPR duration was defined as the time from CPR initiation by EMS personnel to the time of prehospital return of spontaneous circulation or to the time of hospital arrival. The primary outcome was 1-month survival with a favourable neurological outcome (cerebral performance category scale 1 or 2). Statistical analysis was performed with Mann-Whitney U tests for numerical variables and chi-squared test for categorical variables. Univariable and multivariable logistic regression analyses were applied to assess the association between prehospital EMS CPR duration and a favourable neurological outcome, and crude and adjusted odds ratios and their 95% confidence intervals were calculated. RESULTS: The proportion of patients with a favourable neurological outcome was lower in residential locations than in public locations (2.3% [66/2865] vs 10.8% [113/1048]; P < .001). In both univariable and multivariable logistic regression analyses, the proportion of patients with a favourable neurological outcome decreased as prehospital EMS CPR duration increased, regardless of the location of arrests (P for trend <.001). However, some patients achieved a favourable neurological outcome after a prolonged prehospital EMS CPR duration (> 30 min) in both groups (1.4% [6/417] in residential locations and 0.6% [1/170] in public locations). CONCLUSIONS: A longer prehospital EMS CPR duration is independently associated with a lower proportion of patients with a favourable neurological outcome. The association between prehospital EMS CPR duration and neurological outcome differed significantly by location of arrests.

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