The Brighton resuscitation ambulances: a continuing experiment in prehospital care by ambulance staff.

Two ambulances from the existing fleet in Brighton and one in Hove are equipped with portable defibrillator-oscilloscope units. Selected attendants have been trained not only to defibrillate patients but also to perform endotracheal intubation and administer intravenous atropine and lignocaine for carefully defined indications. In the two years up to December 1975 the ambulances responded to 2253 calls which were considered possible emergencies. Retrospective analysis showed that half of these had been for patients with myocardial infarction, coronary insufficiency, or angina. The ambulances took a median time of five minutes to reach a patient. Attempts at resuscitation were made in 207 patients with circulatory arrest, of whom 160 had ventricular fibrillation. Coordinated rhythm was restored at least transiently in 66 patients, and 27 of them survived to leave hospital. Sixteen of the survivors had been in ventricular fibrillation before the arrival of the ambulance. The delay before admission to hospital was reduced: over 50% of patients carried in the ambulances were admitted within two hours of the onset of major symptoms. No extra ambulance staff have been employed for the scheme. The increased load on hospital services has been limited by encouraging a rational admission policy and also by early discharge.     

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.     

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.     

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.     

Early emergency care study: the potential and benefits of advanced prehospital care.

Of 26358 patients taken by ambulance to the accident and emergency departments of two large hospitals, 1185 were admitted to resuscitation areas. The scope for ambulance staff to employ a range of advanced techniques at the scene of incidents was assessed by using information relating to the condition of patients when they were picked up by the ambulance and on admission, time in transit, details from hospital records, and outcome at three months. For non-survivors further assessment was made of the benefit, in terms of survival, which might have accrued had advanced techniques been used. The results of the assessment of benefit were compared with estimates of benefit from other studies. In cases of cardiopulmonary arrest the potential to save lives was less optimistic than earlier estimates, and in cases of trauma the potential to save lives was negligible.     

Role of the general practitioner in managing patients with myocardial infarction: impact of thrombolytic treatment. Report of a British Heart Foundation Working Group.

Thrombolytic treatment, combined with aspirin, has been shown to reduce mortality by half in patients in hospital with suspected acute myocardial infarction if it is given early after the onset of symptoms. This fact adds to the importance of prompt and skillful intervention. At present in the United Kingdom the median time for receiving suitable management for this condition is about four to six hours. With better organisation this delay could, in most areas, be reduced to two or three hours. A major change in the care of patients with myocardial infarction is needed in which the general practitioner should have a crucial role. Health authorities, hospital physicians, general practitioners, and the ambulance services must coordinate their efforts if the potential reduction in mortality is to be realised. The district medical officer should consult colleagues and draw up guidelines for organising the care of patients who have had heart attacks. The management of patients who have had heart attacks in the community and in hospital should be continually audited. There are dangers inherent in the use of thrombolytic treatment, particularly when conditions other than myocardial infarction are treated in error. This treatment should be given only when the diagnosis is highly probable and when close observation of the patient can be ensured during the ensuing hours. Thrombolytic treatment should not, therefore, be given out of hospital except when trained, equipped personnel are in attendance. Treatment can be given in any hospital (including community hospitals) provided there are adequate diagnostic facilities and suitably experienced nursing staff.     

Rectal examination in patients with pain in the right lower quadrant of the abdomen.

OBJECTIVE--To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen. DESIGN--Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital. SETTING--District general hospital. PATIENTS--1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission. MAIN OUTCOME MEASURES--Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis. RESULTS--Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination. CONCLUSION--If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.     

Medical Aspects of Ambulance Design

Various observations have shown that the interior layout of many ambulances leaves much to be desired. The lighting levels are inadequate, heat loss could be prevented, vehicle identification and passage through traffic could be improved, and measurable differences exist between the ride characteristics of commercially available ambulances, a prototype purpose-built ambulance, and a private car. Moreover the condition of some patients may be affected by the motion of the vehicle either directly or indirectly. Even though they form a small percentage of the total number carried, they represent a very considerable financial risk. A personally conducted survey of ambulance chief officers showed a deep interest and involvement in the upgrading of the service with a general dissatisfaction with many of the vehicles currently available. Hence there is a market for the purpose-built ambulance, which would benefit the patient and the ambulanceman alike.The inadequacies of many vehicles currently in use as ambulances have been shown to work against the interests of the patient requiring life support treatment, and it is suggested that this warrants urgent attention and action. A more extensive research project involving medical observations on the supine sick and injured, attendant task performance, and instrumentation analysis of linear and angular vehicle motions should enable the harmful effects of ride motion to be identified.None of these investigations, however, will be of any value unless they are used in developing future ambulances. Such development must also parallel an increase in the awareness of the importance of ambulance design and its relation to the increased comfort and chance of survival of the patients carried.     

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.     

Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London.

OBJECTIVE--To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. DESIGN--Observational study of patients admitted with suspected myocardial infarction during six months. SETTING--Six district general hospitals in Britain. SUBJECTS--1934 patients admitted with suspected myocardial infarction. MAIN OUTCOME MEASURES--Route of admission to hospital and time to admission and thrombolysis. RESULTS--Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. CONCLUSION--The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.     

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.     

Management of asthma in hospital: a prospective audit

In a prospective study of management of asthma in hospital patients with acute asthma admitted to a single hospital over a calendar year were surveyed. Altogether 157 out of 194 admissions (81%) were studied. The patients (16 of whom had been admitted twice and one three times) were interviewed at home about two weeks after discharge, and their hospital records were reviewed. When interviewed an appreciable proportion of patients said that their asthma had been poorly controlled after their discharge from the hospital: 54 reported regular sleep disturbance due to wheeze, 78 tightness of the chest in the morning, and 77 wheeze after climbing one flight of stairs. Patients had been described on admission as having had symptoms of deteriorating asthma for a median of three days. Closer questioning of 71 patients, however, elicited that 50 had had regular symptoms indicating poor control for weeks or months. Most patients did not know how their drugs worked, and many did not have an appropriate plan of action in the event of a further attack. In all the cases studied 114 patients were treated with oral corticosteroids, only 70 had had their previous maintenance treatment increased at the time of discharge, and 107 had a follow up appointment booked for an average of three and a half weeks after discharge.These findings show that undersupervision and undertreatment of patients with asthma are common and not confined to those dying of the condition.     

Simple training programme for ambulance personnel in the management of cardiac arrest in the community.

The extended training for ambulance personnel in Nottinghamshire includes a period of training in cardiac resuscitation by defibrillation, and defibrillators are now part of the standard equipment of vehicles used on the accident and emergency service. Comparison of recent results with previous attempts in the City of Nottingham to provide a service for out of hospital cardiac arrest has shown that an elementary training course and the provision of defibrillators on emergency vehicles enables the ambulance service to save the lives of a reasonable proportion of those who suffer sudden death in the community. The extended training programme as a whole has proved acceptable to ambulance personnel and we believe that this programme could be the basis for a more widespread introduction of post basic training.     

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.     

Randomised trial of a mobile coronary care unit for emergency calls.

A randomised trial was conducted to assess the value of sending a mobile coronary care unit (MCCU) to all emergency calls other than those for children or for patients injured in road-traffic accidents or brawls. Over 15 months 6223 calls for emergency ambulances were considered for the study, but a routine ambulance had to be dispatched on 2583 occasions because the MCCU was not available. A group of 1664 patients was randomly allocated to transport by the MCCU and 1676 patients to routine transport. In these groups the prehospital mortality among patients with heart attacks was 45% and 47%, and no patient survived resuscitation attempts long enough to leave hospital. During the same period general practitioners sent 190 patients with heart attacks to hospital in routine ambulances and none of them died during the interval between the call for the ambulance and arrival at hospital. Although it may be worth equipping all emergency ambulances with a defibrillator, MCCUs as at present envisaged will not appreciably affect mortality from heart attacks.     

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.     

Modes of Admission to Hospital: A Survey of Emergency Admissions to a General Medical Unit

In a survey of the modes of referral and disposal of “acute patients” to a general medical unit during the period 1 February 1968 to 31 July 1970 only 1,432 out of 3,455 were referred by general practitioners. There was a high incidence of self-referral to hospital, and this trend was on the increase. A large percentage of self-referred patients came from their homes, and 65-77% of these arrived by ambulance ordered by themselves.     

Duration of Last Attack in 998 Fatal Cases of Coronary Artery Disease and its Relation to Possible Cardiac Resuscitation

All the deaths attributed to coronary artery disease and occurring in Belfast during one year were studied.The frequency distributions of the cases by interval of time between onset of the last attack and death are given for those not admitted to hospital, for those admitted to hospital, and for those already in hospital for some other cause of illness.Sixty per cent. of all the deaths occurred outside hospital. This indicates that the problem of cardiac resuscitation in coronary artery disease is to a considerable extent an extra-hospital one.Twenty-seven per cent. of the men and 22% of the women died within 15 minutes, but the median period of survival was 3 hours 30 minutes for men and 6 hours 18 minutes for women.The median time interval from the onset of the attack to sending for medical aid was 1 hour 17 minutes for men and 1 hour 6 minutes for women, and from summoning medical aid to sending for the ambulance 59 minutes for men and 1 hour 26 minutes for women. Ninety-six per cent. of the ambulance journeys to the patient were accomplished in less than 20 minutes.It was found among men, but not among women, that the duration of survival tended to be longer in older patients and in second or subsequent attacks.Of the 596 who did not gain admission to hospital 229 (23% of all the 998 patients) were known to have survived for more than half an hour after the onset of the fatal attack; 182 (18%) survived for more than one hour; and 143 (14%) survived for more than two hours. It is among these that there would appear to be special scope for the cardiac ambulance, providing that medical aid is sought and the ambulance is summoned without delay.