Advanced training for ambulance crews: implications from 403 consecutive patients with cardiac arrest managed by crews with simple training.

Sixty seven ambulance staff in Nottinghamshire completed a simple extended training programme in managing cardiac arrest and using a defibrillator. This enabled around one third of the ambulance emergency shifts to be manned by such a crew, with a defibrillator as part of their standard equipment. Forty four of 403 consecutive patients who suffered cardiac arrest in the community were managed by these crews and survived to leave hospital. The training programme does not include endotracheal intubation, intravenous infusion, or drug administration. The new official advanced training course for ambulance crews, which includes these skills, is inappropriate in its methods and may delay widespread introduction of emergency ambulances equipped with defibrillators.     

Use of the automatic external defibrillator-pacemaker by ambulance personnel: the Stockport experience.

In an attempt to reduce the number of people who die from a cardiac arrest in the Stockport area ambulances were equipped with automatic external defibrillator-pacemakers, and ambulance personnel were trained in their use. Over an 18 month period ambulance personnel attended 113 patients in cardiac arrest with these devices. One patient subsequently survived, and three patients survived for up to three days. The reasons for these poor initial results include the failure of bystanders to provide cardiopulmonary resuscitation, a delay in calling for the ambulance, and too few defibrillators being available.     

Resuscitation of patients with cardiac arrest by ambulance staff with extended training in West Yorkshire.

OBJECTIVE--To investigate the results of resuscitation of patients with cardiac arrest by ambulance staff with extended training in West Yorkshire. DESIGN--Study of all such attempts at resuscitation over 32 months, based on the standard report form for each call made by the ambulance staff and the electrocardiogram that showed the initial rhythm in each patient. SETTING--Area covered by West Yorkshire ambulance service. SUBJECTS--1196 Patients with cardiac arrests attended by 29 ambulance staff with extended training. MAIN OUTCOME MEASURE--Result of resuscitation. RESULTS--The initial rhythm was asystole or electromechanical dissociation in 740 patients and ventricular fibrillation in 456 patients; overall 65 patients survived to be discharged from hospital. Sixty four of the 456 patients in whom ventricular fibrillation was the initial rhythm recorded, and 46 in whom ventricular fibrillation persisted after the ambulance staff arrived, survived. Only one of the 740 patients who initially had asystole or electromechanical dissociation survived. Factors associated with a greater chance of ventricular fibrillation occurring were: age less than 71, the arrest being witnessed by a bystander, resuscitation by a bystander, the arrest occurring in a public place, and a response time by the ambulance staff of less than six minutes. For patients found in ventricular fibrillation a shorter response time was associated with improved survival but resuscitation by a bystander was not. Additional skills learnt during extended training were used for 51 of the 65 patients who survived. CONCLUSIONS--Ambulance staff with extended training can save the lives of patients with cardiac arrest due to fibrillation, though asystole and electromechanical dissociation have a poor prognosis and should perhaps receive little attention during extended training.     

Home Care Providers to the Rescue: A Novel First-Responder Programme

AimTo describe the implementation of a novel first-responder programme in which home care providers equipped with automated external defibrillators (AEDs) were dispatched in parallel with existing emergency medical services in the event of a suspected out-of-hospital cardiac arrest (OHCA).MethodsWe evaluated a one-year prospective study that trained home care providers in performing cardiopulmonary resuscitation (CPR) and using an AED in cases of suspected OHCA. Data were collected from cardiac arrest case files, case files from each provider dispatch and a survey among dispatched providers. The study was conducted in a rural district in Denmark.ResultsHome care providers were dispatched to 28 of the 60 OHCAs that occurred in the study period. In ten cases the providers arrived before the ambulance service and subsequently performed CPR. AED analysis was executed in three cases and shock was delivered in one case. For 26 of the 28 cases, the cardiac arrest occurred in a private home. Ninety-five per cent of the providers who had been dispatched to a cardiac arrest reported feeling prepared for managing the initial resuscitation, including use of AED.ConclusionHome care providers are suited to act as first-responders in predominantly rural and residential districts. Future follow-up will allow further evaluation of home care provider arrivals and patient survival.     

Paramedics and technicians are equally successful at managing cardiac arrest outside hospital.

OBJECTIVE--To examine the effect on survival of treatment by ambulance paramedics and ambulance technicians after cardiac arrest outside hospital. DESIGN--Prospective study over two years from 1 April 1992 to 31 March 1994. SETTING--Accident and emergency department of university teaching hospital. SUBJECTS--502 consecutive adult patients with out of hospital cardiopulmonary arrest of cardiac origin. INTERVENTIONS--Treatment by ambulance technicians or paramedics both equipped with semiautomatic defibrillators. MAIN OUTCOME MEASURES--Rate of return of spontaneous circulation, hospital admission, and survival to hospital discharge. RESULTS--Rates of return of spontaneous circulation, hospital admission, and survival to hospital discharge were not significantly different for patients treated by paramedics as opposed to ambulance technicians. Paramedics spent significantly longer at the scene of the arrest than technicians (P < 0.0001). CONCLUSIONS--The response of ambulance paramedics to patients with cardiopulmonary arrest outside hospital does not provide improved outcome when compared with ambulance technicians using basic techniques and equipped with semi-automatic defibrillators.     

Mobile Coronary Care Provided by Ambulance Personnel

Mobile coronary care has been provided in Brighton by ambulance personnel without immediate help from physicians or nurses. No additional vehicles or staff were required. The capital cost of the experiment was therefore small and additional running costs were negligible. The results have been monitored by retrospective analysis of electrocardiograms recorded in the ambulance and stored on magnetic tape. In the first 12 months of operation to July 1972, 1,082 patients with suspected cardiac emergencies were carried in two vehicles. Subsequent analysis showed that 76% of these patients had acute symptoms from ischaemic heart disease or had circulatory arrest. Eighty-six per cent. of arrhythmias were diagnosed correctly by the ambulance attendants. Though only eight cases of primary ventricular fibrillation occurred during or shortly before transit all were successfully reversed, and five of these patients subsequently left hospital alive. Other benefits of the scheme have included an appreciable reduction in the median delay between onset of presenting symptoms in patients with acute myocardial ischaemia and their admission to hospital.     

Follow-up of emergency ambulance calls in Nottingham: implications for coronary ambulance servie.

Information about patients in ambulance service records has been linked to that in the patients'' hospital records in an attempt to make the most efficient use of a special ambulance service for patients suspected of having heart attacks. During one week 248 emergency (999) calls for an ambulance were made by the public in the city of Nottingham. The quality of information given to the ambulance centre was poor, and all four patients eventually found to have had a myocardial infarction were described as having collapsed. A further study of patients who were also described as having collapsed has led to a system which allows an ambulance controller to send a "coronary ambulance" only in answer to those emergency calls where there is a reasonable possibility that the patient has had a heart attack.     

Pre-hospital Coronary Care Service

The Dublin cardiac ambulance service operates two specially-equipped ambulances from a private ambulance station; five metropolitan hospitals provide coronary care beds on a rota system. The service covers an area of 450 square miles (1,165 sq km) and a population of 800,000. The ambulances are staffed solely by trained ambulance personnel. During the first three years 1,973 patients were transported to hospital. Primary ventricular fibrillation was encountered in 20 patients and successfully treated in 17. No deaths occurred in the ambulance.Over 98% of the patients were transferred uneventfully to hospital, so a medical team from the hospital on duty was called on 30 occasions only. A feature of the Dublin service is the low cost of a standard ambulance call, at about £7·50.     

Sudden cardiac arrest on the field of play: turning tragedy into a survivable event

Sudden cardiac arrest remains the leading cause of death in exercising athletes, and recent studies have shown that it occurs more frequently than historical estimates. While out-of-hospital cardiac arrest often proves fatal, advance preparation can improve outcomes and the chance of survival. First responders to a collapsed athlete on the field of play may include team medical personnel, coaches, other athletes, officials, venue staff, emergency medical services personnel, or lay bystanders. Prompt and accurate recognition of sudden cardiac arrest, a comprehensive and rehearsed emergency action plan, early cardiopulmonary resuscitation, and immediate access to and use of an automated external defibrillator are each pivotal links in the chain of survival. This review summarises the components of an effective emergency action plan, highlights the critical role of automated external defibrillators, and reviews the diagnosis and management of sudden cardiac arrest on the field of play.     

Effects of 24-Hour Shift Work with Nighttin Napping on Circadian Rhythm Characteristi in Ambulance Personnel

Forty-two ambulance personnel engaged in a 24-h shift system participated in a chronobiological field study to study the effects of 24-h shift work on circadian rhythm characteristics. Autorhythmometry of circadian rhythms of oral temperature, right and left grip strengths, and heart rate plus subjective assessment of drowsiness, fatigue, and attention was performed every ～ 4 h except during sleep for 7 days. Cosinor and power spectral analyses were applied to the longitudinal data of each individual. Changes in circadian period different from 24 h of oral temperature, grip strengths, and heart rate plus subjective drowsiness, fatigue, and attention were observed in ambulance personnel. The incidence of circadian periodicity different from 24 h in oral temperature and right and left grip strength was 28.6%, 35.7%, and 47.6%, respectively. The incidence was relatively lower than that of shift workers engaged in a discontinuous 8-h shift system we reported on previously. Working conditions allowing ambulance personnel to nap when not called for emergency (for > 4 h) might contribute to a stabilization of circadian rhythms. Furthermore, long nighttime ambulance service amounting to >100 min was significantly associated with a high incidence of at least one prominent circadian period among oral temperature and right and left grip strength rhythms different from 24 h. In conclusion, 24-h shift work altered the characteristics of circadian rhythms of ambulance personnel; nighttime naps seemed to have a favorable effect on averting changes in circadian rhythms.     

Importance of patient selection in evaluating a cardiac ambulance service.

All patients brought to hospital by a special cardiac ambulance were followed up and compared with patients carried by routine ambulances to assess the effectiveness of a cardiac ambulance service. The overall mortality of patients with heart attacks was 51% among those carried by an ordinary ambulance and 40% among those carried by the cardiac ambulance. The apparently low mortality in the latter group was balanced, however, by a high mortality (68%) among patients carried by ordinary ambulances when the cardiac ambulance was available but not used; these patients tended to have a short duration of symptoms and heart attacks away from home, and their ambulance was more often called by a member of the public than a general practitioner. It seems therefore that low-risk cases were inadvertently selected for transport by the cardiac ambulance; such unintentional selection makes it difficult to evaluate a cardiac ambulance service.     

Heart-Alert: emergency resuscitation training in the community

One approach to reducing avoidable mortality from coronary artery disease is to provide resuscitation capability in the community. In Manitoba this is the function of the Heart-Alert program, sponsored by the Manitoba Heart Foundation. The program is based on public and professional education dealing with the recognition and immediate care of cardiac emergencies, including cardiopulmonary resuscitation (CPR). The three components to the program are (a) training in basic CPR for all health care and community rescue groups; (b) training in definitive CPR for physicians, critical care nurses and advanced emergency medical technicians; and (c) education of the public to recognize the signs of impending or actual cardiac emergencies and to take appropriate action to summon quickly an emergency rescue team.The initial emphasis of the program has been on developing an organizational structure and a training network for basic CPR. A corps of instructor-trainers and instructors has been certified to implement CPR training in the medical and community target groups. Developmental problems include problems of quality control, of providing for self-sustaining and continued expansion, and of evaluation of the overall results.It is suggested that widespread implementation of CPR training is facilitated by the incorporation of CPR into existing training activities, particularly those of the medical, nursing and other health care disciplines, those of community protection agencies such as police, fire and ambulance departments, and those of volunteer groups concerned with rescue work and first-aid. If the impetus, organizational structure and instructor training are provided by a strategic agency, wide dissemination of CPR training is then possible at relatively modest cost.     

Acute cardiovascular failure and its treatment--value of defibrillation in preclinical management]

Ventricular fibrillation is the most common cause of cardiac arrest. The only scientifically proved therapy that guarantees a long time survival is the early electrical defibrillation. As early as 200 years ago electricity was employed in trying to regain circulation in cases of unexpected death. In the field of emergency medicine almost all rescue services are equipped with defibrillators nowadays and the personnel is trained in using them. Since the application of electricity on the myocardium can lead to damage, there are devices with a varied defibrillation pulse available since recently. The advantage of the biphasic defibrillation is a less harmful impact on the myocardium at lower shock intensity. A further novelty which enables the application by groups other than the rescue services, is the automatic external defibrillator (AED). Extending the availability of defibrillators can contribute to an increase in the presently low success rates of resuscitation.     

An Observational Study of Patient Characteristics Associated with the Mode of Admission to Acute Stroke Services in North East,England

Objective

Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services.

Study design and setting

A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases.

Results

Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis.

Conclusion

Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations.     

General practitioner attendance at emergencies notified to ambulance control.

For two years doctors from a small village went to the scene of emergency calls received by ambulance control. On 80% of the occasions when the doctor was called at the same time as the ambulance was dispatched the doctor arrived before the ambulance. There were 24 incidents, 16 of which were road traffic accidents. In two cases the doctor established a clear airway in an unconscious patient before the ambulance arrived. Two patients were trapped in their vehicles and were given parenteral analgesics. Four patients required intravenous fluids. The call out system provided first aid for patients before the ambulance arrived and medical assistance to the emergency services at serious accidents. Patients who did not require hospital attention could be examined and treated at the scene, making the ambulance available for other duties and reducing the number of patients taken to the hospital accident and emergency department.     

Accident Flying Squad

This paper describes the organization, evaluation, and costing of an independently financed and operated accident flying squad. 132 accidents involving 302 casualties were attended, six deaths were prevented, medical treatment contributed to the survival of a further four, and the condition or comfort of many other casualties was improved. The calls in which survival was influenced were evenly distributed throughout the three-and-a-half-year survey and seven of the 10 so aided were over 16 and under 30 years of age, all 10 being in the working age group.The time taken to provide the service was not excessive and the expense when compared with the overall saving was very small. The scheme was seen to be equally suitable for basing on hospital or general practice or both, and working as an integrated team with the ambulance service. The use of specialized transport was found to be unnecessary. Other benefits of the scheme included use of the experience of attending accidents to ensure relevant and realistic training for emergency service personnel, and an appreciation of the effect of ambulance design on the patient.     

Incidence and costs of severe hypoglycaemia requiring attendance by the emergency medical services in South Central England

Aims The aim was to estimate the incidence of severe hypoglycaemia requiring emergency ambulance assistance, its management and associated costs. Methods A retrospective observational study used routinely collected data for a 1-year period from December 2009 to November 2010 from the South Central Ambulance Service National Health Service Trust, UK. The main outcome was episodes reported by ambulance personnel and costs were estimated from published data. Results During the 1-year study period, 398?409 emergency calls were received, of which 4081 (1.02%) were coded as hypoglycaemia. The overall numbers (and annual rate) of hypoglycaemia recorded among people ≥?15?years with presumed diabetes was 3962 (2.1%), but for those aged 15-35?years was 516 (7.5%) and for those aged ≥?65?years was 1886 (1.9%). Of those attended, 1441 (35.3%) were taken to hospital. The estimated total cost of initial ambulance attendance and treatment at scene was ￡553?000; if transport to hospital was necessary, the additional ambulance costs were ￡223?000 plus emergency department costs of ￡140?000; and the cost of primary care follow-up was estimated as ￡61?000. The average cost per emergency call was ￡263. The estimated annual cost of emergency calls for severe hypoglycaemia is ￡13.6m for England. Conclusions Our estimates suggest prevalence of severe hypoglycaemia attended by the emergency services is high in younger age groups and lower for older age groups, although the absolute numbers of severe events in older age groups contribute substantially to the overall costs of providing emergency assistance for hypoglycaemia.     

Canadian ground ambulance services: provincial funding and standards for equipment and training.

There is an increasing demand for improved, up-to-date training and equipment for ground ambulance services across Canada. This paper presents the results of a survey of ambulance operations and their funding by the provinces, as well as a comparison of provincial legislation and recommendations on standards for equipment and the training of ambulance personnel. The training standards were found to be very diverse, and the legislated or recommended equipment standards did not meet those of the American College of Surgeons committee on trauma (ACSCT). The cost of ambulance services per capita and the cost to the user of an average 43-km run varied widely between the provinces. There was no correlation between the second cost and how well the province met the ACSCT''s equipment standards.     

Management of cardiac arrest in the community: a survey of resuscitation services.

A survey of the English health regions identified nine ambulance based resuscitation schemes. Their structure and function are heterogeneous and their impact on patient survival is often speculative. There is considerable medical, paramedical, and lay enthusiasm for resuscitation schemes but this cannot be harnessed until medicolegal uncertainties are removed and guidelines for development are set out. Better documentation of the benefits of existing schemes should be undertaken so that advanced training of ambulance personnel can proceed rationally.