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Various initiatives are using emergency medical service personnel to address critical problems in local U.S. delivery systems, such as insufficient primary and chronic care resources, overburdened EDs, and costly, fragmented emergency and urgent care networks. Growing increasingly short of breath late one night, Ms. E. called her health care provider’s urgent care line, anticipating that the on-call nurse practitioner would have her transported to the emergency department (ED). Over the past 6 months, Ms. E. had made many ED visits. She is 83 years old and poor, lives alone, and has multiple health problems, including heart failure, advanced kidney disease, hepatitis C with liver cirrhosis, diabetes, and hypertension. In the ED, she generally endures long waits, must repeatedly recite her lengthy medical history, and feels vulnerable and helpless. She was therefore relieved when, instead of . . .

The power and sophistication of terrorist bombings have increased dramatically, but America's emergency and trauma care system has deteriorated to an alarming degree. Dr. Arthur Kellermann writes that strengthening disaster response is a key priority. At 2 a.m. on July 27, 1996, I stood in the ambulance bay of Grady Memorial Hospital, awaiting the first of 35 severely injured bombing victims who would be brought to Grady from Atlanta's Olympic Park over the next 2 hours. Although it was a harrowing experience for all involved, the response of Grady's ambulance service, emergency physicians, and trauma surgeons was so efficient that the hospital had returned to normal operations by 7 a.m. Much has changed in the decade since the Atlanta bombing. The power and sophistication of terrorist bombings have increased dramatically, but America's emergency and trauma . . .

ObjectiveTo explore the experience of psychological distress and well-being in emergency medicine (EM) consultants.MethodsA qualitative, interpretative phenomenological analysis (IPA) study based on 1:1 semistructured interviews with EM consultants working full time in EDs across South West England. Eighteen EM consultants were interviewed across five EDs, the mean (SD) age of participants being 43.17 (5.8) years. The personal meanings that participants attached to their experiences were inductively analysed.ResultsThe analysis formed three superordinate themes: systemic pressures, physical and mental strain and managing the challenges. Pressures within the ED and healthcare system contributed to participants feeling undervalued and unsatisfied when working in an increasingly uncontrollable environment. Participants described working intensely to meet systemic demands, which inadvertently contributed to a diminishing sense of achievement and self-worth. Consultants perceived their experience of physical and emotional strain as unsustainable, as it negatively impacted; functioning at work, relationships, personal well-being and the EM profession. Participants described how sustainability as an EM consultant could be promoted by social support from consultant colleagues and the ED team, and the opportunity to develop new roles and support ED problem solving at an organisational level. These processes supported a stigma-reducing means of promoting psychological well-being.ConclusionsEM consultants experience considerable physical and mental strain. This strain is dynamically related to consultants' experiences of diminishing self-worth and satisfaction, alongside current sociopolitical demands on EM services. Recognising the psychological experiences and needs of EM consultants and promoting a sustainable EM consultant role could benefit individual psychological well-being and the delivery of emergency care.

The application of a cervical collar is a standard procedure in trauma patients in emergency medicine. It is often observed that cervical collars are applied incorrectly, resulting in reduced immobilization of the cervical spine. The objective of this study was to analyze the practical skills of trained professional rescue personnel concerning the application of cervical collars. Within emergency medical conferences, n = 104 voluntary test subjects were asked to apply a cervical collar to a training doll, wherein each step that was performed received an evaluation. Furthermore, personal and occupational data of all study participants were collected using a questionnaire. The test subjects included professional rescue personnel (80.8%) and emergency physicians (12.5%). The average occupational experience of all study participants in pre-clinical emergency care was 11.1±8.9 years. Most study participants had already attended a certified training on trauma care (61%) and felt \"very confident\" in handling a cervical collar (84%). 11% applied the cervical collar to the training doll without errors. The most common error consisted of incorrect adjustment of the size of the cervical collar (66%). No association was found between the correct application of the cervical collar and the occupational group of the test subjects (trained rescue personnel vs. emergency physicians) or the participation in certified trauma courses. Despite pronounced subjective confidence regarding the application of cervical collars, this study allows the conclusion that there are general deficits in practical skills when cervical collars are applied. A critical assessment of the current training contents on the subject of trauma care must, therefore, be demanded.

Introduction Road traffic collisions are a common cause of injuries and injury-related deaths in sub-Saharan Africa (SSA). Basic prehospital care can be the difference between life and death for injured drivers, passengers, and pedestrians. Problem This study examined the challenges associated with current first response practices in Malawi. In April 2014, focus groups were conducted in two areas of Malawi: Karonga (in the Northern Region) and Blantyre (in the Southern Region; both are along the M1 highway), and a qualitative synthesis approach was used to identify themes. All governmental and nongovernmental first response organizations identified by key informants were contacted, and a checklist was used to identify the services they offer. Access to professional prehospital care in Malawi is almost nonexistent, aside from a few city fire departments and private ambulance services. Rapid transportation to a hospital is usually the primary goal of roadside care because of limited first aid knowledge and a lack of access to basic safety equipment. The key informants recommended: expanding community-based first aid training; emphasizing umunthu (shared humanity) to inspire bystander involvement in roadside care; empowering local leaders to coordinate on-site responses; improving emergency communication systems; equipping traffic police with road safety gear; and expanding access to ambulance services. Prehospital care in Malawi would be improved by the creation of a formal network of community leaders, police, commercial drivers, and other lay volunteers who are trained in basic first aid and are equipped to respond to crash sites to provide roadside care to trauma patients and prepare them for safe transport to hospitals. Chokotho L , Mulwafu W , Singini I , Njalale Y , Maliwichi-Senganimalunje L , Jacobsen KH . First responders and prehospital care for road traffic injuries in Malawi. Prehosp Disaster Med. 2017;32(1):14-19.

To 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). We 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. Home 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. Home 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.

Purpose To prospectively evaluate the implementation of a rapid response team in the form of a medical emergency team (MET) with regard to cardiac arrests and hospital mortality. Methods Prospective before-and-after trial of implementation of a MET at the Karolinska University Hospital, Stockholm, Sweden. All adult patients, apart from cardiothoracic, admitted to the hospital were regarded as participants in the study. A control period of 5 years and 203,892 patients preceded the 2-year intervention period of 73,825 patients. Main results Number of MET calls was 9.3 per 1,000 hospital admissions. Cardiac arrests per 1,000 admissions decreased from 1.12 to 0.83, OR 0.74 (95% CI 0.55–0.98, p  = 0.035). Adjusted for age, sex, hospital length of stay, acute/elective admission as well as co-morbidities, MET implementation was associated with a reduction in total hospital mortality by 10%, OR 0.90 (95% CI 0.84–0.97), p  = 0.003. Hospital mortality was also reduced for medical patients by 12%, OR 0.88 (95% CI 0.81–0.96, p  = 0.002) and for surgical patients not operated upon by 28%, OR 0.72 (95% CI 0.56–0.92, p  = 0.008). For patients fulfilling the MET criteria Thirty-day mortality pre-MET was 25% versus 7.9% following MET compared with historical controls. Similarly, 180-day mortality was 37.5% versus 15.8%, respectively. Conclusions Implementing the MET team was associated with significant improvement in both cardiac arrest rate and overall adjusted hospital mortality. Significant reductions in hospital mortality for un-operated surgical patients as well as for medical patients were also seen. Thus, introduction of the MET seemed to improve outcome for hospitalized patients.

Purpose To assess the accuracy of best-corrected visual acuity (BCVA) measured by non-ophthalmic emergency department (ED) staff with a standard Snellen chart versus an automated application (app) on a handheld smartphone (Paxos Checkup, San Francisco, CA, USA). Methods The study included 128 subjects who presented to the Stanford Hospital ED for whom the ED requested an ophthalmology consultation. We conducted the study in two phases. During phase 1 of the study, ED staff tested patient BCVA using a standard Snellen test at 20 feet. During phase 2 of the study, ED staff tested patient near BCVA using the app. During both phases, ophthalmologists measured BCVA with a Rosenbaum near chart, which was treated as the gold standard. ED BCVA measurements were benchmarked prospectively against ophthalmologists’ measurements and converted to logMAR. Results ED logMAR BCVA was 0.21 ± 0.35 (approximately 2 Snellen lines difference ± 3 Snellen lines) higher than that of ophthalmologists when ED staff used a Snellen chart ( p  = .0.00003). ED BCVA was 0.06 ± 0.40 (less than 1 Snellen line ± 4 Snellen lines) higher when ED staff used the app ( p  = 0.246). Inter-observer difference was therefore smaller by more than 1 line (0.15 logMAR) with the app ( p  = 0.046). Conclusions BCVA measured by non-ophthalmic ED staff with an app was more accurate than with a Snellen chart. Automated apps may provide a means to standardize and improve the efficiency of ED ophthalmologic care.

The objectives were to assess changes in (1) health and physical fitness, (2) the prevalence of selected health problems, (3) risk behaviors, (4) ambulance safety issues, and (5) the preparedness of Emergency Medical Services (EMS) professionals. In addition, the incidence of patient-initiated violence directed toward EMS personnel and associated factors were assessed. Data were obtained from a sample of nationally certified EMS professionals via annual questionnaires between 1999 and 2008. Stratification was based upon national certification level, self-reported race, and experience level. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted by lack of CI overlap. The proportion reporting \"excellent\" health declined significantly from 1999 (38.5%) to 2008 (32.2%). High rates of sleeping problems (20%-27%), back problems (20%-24%), and hearing problems (7%-10%) were reported as having occurred in the past year. These rates remained constant over time. As a result of sleepiness, 8.0% of nationally certified EMS professionals reported difficulty in driving an emergency vehicle for short distances and 17.5% reported difficulty in driving long distances. The proportion of daily tobacco smokers significantly declined from over one-third (35.3%) to about one-fifth (20.3%). The proportion of providers who had ever been involved in an ambulance crash increased slightly from 2004 (14.5%) to 2008 (15.8%). In 2000, the majority of EMS professionals reported that they and/or their partner had been assaulted by a patient. Finally, there was a significant decrease in the amount of training time devoted to the recognition of biological, chemical, and nuclear (BCN) threats, use of personal protective equipment (PPE), and treatment and management of patients exposed to BCN from an average from 8.4 hours in 2003 to 6.2 hours in 2008. The overall health and physical fitness of EMS professionals as well as their health problems, risk behaviors, ambulance safety, and patient-initiated violence in the prehospital emergency setting are areas of concern for the nation's emergency medical system. The prevalence of these problems and overall health and physical fitness has shown little or no improvement from 1999 to 2008. Bentley MA , Levine R . A national assessment of the health and safety of Emergency Medical Services professionals. Prehosp Disaster Med. 2016;31(Suppl. 1):s96-s104.

Background There is an increasing global recognition of the role of emergency medical services in improving population health. Emergency medical services remain underdeveloped in many low income countries, particularly in sub-Saharan Africa. There have been no previous evaluations of specialist emergency and critical care services in Sierra Leone. Methods Emergency care capacity was evaluated at a sample of seven public and private hospitals in Freetown, the capital of Sierra Leone. A structured set of minimum standards necessary to deliver emergency and critical care in the low-income setting was used to evaluate capacity. The key dimensions of capacity evaluated were infrastructure, human resources, drug and equipment availability, training, systems, guidelines and diagnostics. A score for each dimension of capacity was calculated based on the availability of a list of specified indicators within each dimension. In addition, an Emergency Care Capacity Score was calculated to demonstrate a composite measure of capacity based on the various indicator scores. This method has been used by the World Health Organisation in evaluating the availability and readiness of healthcare systems in low- and middle-income countries. Results Substantial deficiencies in capacity were demonstrated across the range of indicators and predominantly affecting publically funded facilities. Capacity was weakest in the domain of infrastructure, with an average score of 43%, while the strongest areas of capacity overall were in drug availability, 82%, and human resources, 79%. A marked disparity was noted between public and private healthcare facilities with consistently lower capacity in the former. The overall Emergency Care Capacity Score was 66%. Conclusion There are substantial deficiencies in emergency care systems in public hospitals in Freetown which are likely to compromise effective care. This represents a serious barrier to access to emergency healthcare. Emergency care systems have an important role in improving population health and as such should a priority for local policy makers.