Faculty Bibliography

INTRODUCTION/BACKGROUND:Many emergency medical services (EMS) systems in the United States utilize statewide protocols, but the number, type, and role of these systems in prehospital decision-making are largely unknown. STUDY OBJECTIVE/OBJECTIVE:To characterize statewide protocols and determine their role in prehospital decision-making. METHODS:All states were queried for the presence of mandatory statewide Advanced Life Support (ALS)-level EMS protocols. Protocols were categorized as diagnosis-based, symptom-based, procedural, or non-clinical by two fellowship-trained EMS physicians. A data abstraction guide with category examples was included. Discrepancies were resolved by a third blinded EMS physician. The number and type of protocols were compiled, and simple statistics and chi-squared analysis were used to evaluate state-by-state variation. RESULTS:Nine states have mandatory statewide ALS protocols, totaling 804 individual protocols, including 672 (83.6%) clinical and 132 (16.4%) non-clinical protocols. Symptom-based protocols accounted for 59.5% of the clinical protocols, while 13.2% were diagnosis-based and 27.2% procedural. Per state, there was a median interquartile range (IQR) of 46 (14.5) symptom-based, 8 (8) diagnosis-based, and 17 (22.5) procedural protocols. There was significant variation in the type and number of protocols by state (p < 0.001). CONCLUSION/CONCLUSIONS:Significant variation exists in statewide EMS protocols. While many are symptom-based, a notable portion are diagnosis-based, challenging the notion that paramedics cannot diagnose. These findings suggest a need for higher-level clinical decision-making in EMS. Further research is warranted at other EMS training levels and to inform EMS training programs.

OBJECTIVE:Studies have shown a bougie improves first-attempt success rates when used in combination with direct laryngoscopy during the initial attempt. The purpose of this study was to determine whether the use of a bougie in combination with C-MAC (Karl Storz, Tuttlingen, Germany) improves first-attempt success rates of endotracheal intubation (ETI) compared with C-MAC with a traditional stylet. METHODS:This study is a retrospective chart review using data collected on 371 intubations completed by a single air medical service using the C-MAC laryngoscope and either a bougie or a stylet. RESULTS: = 0.743, P = .7). CONCLUSION:There was no difference between first-attempt success rates using video laryngoscopy with a bougie, overall intubation success rates, or difficult intubation success rates compared with video laryngoscopy with a stylet, indicating that the purpose of a bougie as a rescue device did not hold true in the prehospital setting of our critical care air medical service.

Abdominal pain is a common chief complaint seen in the emergency department (ED), both in adult and pediatric populations. In pediatric emergency medicine, one diagnosis that is often considered is intussusception; in adult emergency medicine, this is typically less common. The classic teaching in adults is that the most common cause of intussusception is malignancy. In the following case report, however, the etiology of intussusception was not from malignancy but rather idiopathic. This case report describes an elderly female presenting to the ED for abdominal pain, nausea, vomiting, and hematochezia. She underwent abdominal imaging with findings concerning for intussusception; this necessitated urgent operative intervention. She was found to have ileocolonic intussusception. Tissue biopsy was sent for analysis to evaluate for malignancy. This was negative. While emergency physicians often keep intussusception high on their list of differential diagnoses when dealing with pediatric patients with abdominal pain, it is rarely considered in the adult population. Abdominal pain is one of the most common chief complaints seen in emergency medicine. Intussusception should definitely be considered as this could be the etiology of abdominal pain and, in rare circumstances, the potential etiology for an acute abdomen.

BACKGROUND:Current guidelines for the treatment of adult patients in cardiac arrest are supplied by the American Heart Association through basic life support and advanced cardiovascular life support (ACLS) provider courses. When treatments defined by the ACLS guidelines are unsuccessful in terminating a lethal dysrhythmia, the use of alternative strategies may prove useful. In this case, two defibrillators were used to deliver a greater than normal energy waveform over an extended time interval to return a patient to a normal sinus rhythm. CASE REPORT/METHODS:A 56-year-old woman presented to the emergency department with complaints of chest pain, nausea, and vomiting. The patient's initial work-up, including an electrocardiogram and cardiac troponin, did not show evidence of acute ischemia, and she was admitted to the observation unit for further evaluation. While in the emergency department, the patient developed ventricular fibrillation, and ACLS was initiated. After four unsuccessful defibrillation attempts, a second defibrillator was placed on the patient, and the two were activated almost simultaneously. The patient had immediate return of spontaneous circulation, underwent cardiac catheterization, and was discharged home 1 week later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case shows that dual sequential defibrillation may be a successful method for terminating refractory ventricular fibrillation. Further investigation on cardiac resuscitation should be conducted to standardize the dual sequential defibrillation delivery procedure. Until such guidelines are established, physicians should take this treatment into consideration when standard ACLS measures have failed to successfully terminate refractory ventricular fibrillation.