Sztajnkrycer, Matthew D.

ImportanceThere is a clear benefit to body armor against firearms; however, it remains unclear how these vests may influence day-to-day patient encounters when worn by emergency medical services (EMS).ObjectiveTo determine the association of ballistic vests worn by EMS clinicians with workplace violence (WPV) and disparities in care among racial and/or ethnic minority patients.Design, Setting, and ParticipantsProspective cohort study of a volunteer-based sample of EMS clinicians at a large, multistate EMS agency encompassing 15 ground sites across the Midwest from April 1, 2023, to March 31, 2024. Data were analyzed from May to June 2024.ExposureExternal ballistic armor being used by a group of self-selected clinicians on every run.Main Outcomes and MeasuresPrevalence and characteristics associated with WPV and with declines of treatment and/or transport compared between crews with 1 or more vested vs no vested members.ResultsA total of 156 of 415 staff (37.6%) opted in to wear the vests, including 77 male participants (49.4%). Prevalence of WPV was higher for vested crews (1.11 vs 0.85 cases per 100 runs; adjusted risk ratio [aRR], 1.28; 95% CI, 1.10 to 1.50; P = .001) and was due to higher rates of verbal abuse. The presence of 1 or more vested crew members increased the likelihood of all patients declining EMS treatment and/or transport; however, effect size was highest among patients with an unknown race and/or ethnicity (2234 [21.1%] vs 2134 [16.5%] patients; aRR, 1.19; 95% CI, 1.10 to 1.27; P < .001), followed by racial and/or ethnic minority patients (708 [16.7%] vs 399 [13.8%] patients; aRR, 1.18; 95% CI, 1.05 to 1.33; P = .01). Analyses of individual minority groups revealed a significant increase only in Black or African American patients declining treatment and/or transport by vested crews (461 [17.6%] vs 223 [13.7%] patients; RR, 1.28; 95% CI, 1.10 to 1.49; P = .002).Conclusions and RelevanceIn this cohort study, vested crews experienced increased prevalence of WPV compared with nonvested crews. Use of vests increased the frequency of all patients declining EMS treatment and/or transport. Among minority groups, there was a significant increase in Black or African American patients declining treatment and/or transport. Agencies should consider benefits and unintended consequences of EMS clinicians wearing body armor.

Objectives Pediatric refusal of medical assistance (RMA) is a potentially high-risk event with implications for both individual patient outcomes and greater emergency medical services system efficiency. The purpose of this study was to describe characteristics of pediatric RMA calls and outcomes. Methods Single emergency medical services agency retrospective study of calls between January 1, 2011, and December 31, 2015, for pediatric patients resulting in RMA was performed. Dispatch complaint-matched case-control group was generated from transported patients. Results The percentage of pediatric calls that resulted in RMA was 12.7%, compared with 5% adult calls (P < 0.0001). The 3 most common RMA dispatch complaints were seizures, difficulty breathing, and traffic accidents. Furthermore, 65.1% pediatric RMA calls were emergently dispatched, compared with 56.4% of transported pediatric patients (P = 0.01). Medical control was contacted for 4.6% RMA calls. The average ± SD word count for RMA patient care narratives was 179 ± 99 words, compared with 164 ± 139 words for controls (P = 0.11). Documentation of risk-benefit discussion occurred in 28.6% RMA narratives. Outcome data were available for 83.8% RMA patients. The percentage of RMA patients with documented alternative plans who completed the alternative plan was 61.6%. Within 72 hours of RMA, 5.0% of calls with known outcome resulted in unexpected emergency department visit. No unexpected emergency department visits resulted in admission. Five percent of RMA patients were admitted; 1 patient was admitted to the intensive care unit. No emergent surgeries or deaths occurred during the study period. Conclusions Pediatric RMA is common within our study population, and two thirds involve emergent dispatch. Although outcomes are generally good, refusal documentation is sparse and medical control is seldom contacted. Multiple opportunities for systems improvement exist.

Abstract Objective The American College of Surgeons (ACS) encourages clinicians to provide training to laypeople on tourniquet application. It is unclear whether clinicians are confident in their abilities and equipped with adequate knowledge, skills, and resources. This study aimed to determine surgical trainee knowledge and attitudes regarding tourniquet application and compare the effectiveness of instructions. Methods Thirty surgical trainees performed a tourniquet application simulation using a Combat Application Tourniquet and one of the three instructions sets developed by ACS, Department of Homeland Security, and the tourniquet manufacturer. Participants reported tourniquet knowledge, attitudes, and confidence and discussed the instructions. One instruction set was updated and compared to the original set with 20 new trainees. Results Participants with ACS instructions passed the greatest number of steps (p &lt; 0.01) and completed the task significantly faster compared to those with manufacturer instructions (p &lt; 0.01). Participants (80%) reported favorable views toward tourniquets but 30–60% did not align with to ACS tourniquet guidelines. Focus group participants suggested revisions to the ACS instructions. Comparing the original and revised version of these instructions resulted in no significant improvements. Conclusions ACS instructions provide guidance; however, improvements to tourniquet instruction are needed for success in controlling exsanguinating hemorrhage.

AbstractObjectivesA cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient’s mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions.MethodsBoth a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions.ResultsThe IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p &lt; 0.03) and minute ventilation (p &lt; 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p &lt; 0.01), decreased user effort (p &lt; 0.001), and reduced upper limb workload (p = 0.0088).ConclusionsIn the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.

AbstractBackgroundCurrent military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.MethodsFive different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet – Wide), SWAT-T (Stretch Wrap and Tuck – Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25” to 16.5”. Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).ResultsIn both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75” circumference or smaller (age &lt; 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25” and 15.5” circumference PVC pipes (age 7–12 years lower extremity, age &gt;13 years upper extremity). The SWAT-T was tightened on all PVC pipes.DiscussionThe current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.

The Stop The Bleed initiative was developed by the Department of Homeland Security to educate lay providers in bleeding reduction strategies. The current study evaluated: (1)three tourniquet instructions using a simulated tourniquet task and (2)participant confidence levels in tourniquet use and lay provider training. Thirty participants with limited clinical experience applied a tourniquet to a simulated limb using one of three instruction sets. Twelve of these participants (40%) participated in a tourniquet training session and focus group to discuss each instruction set. Participants preferred the most simple and pictoral instruction set, and identified opportunities for improvement in each set. Participant confidence in tourniquet use increased significantly following the task and the focus group. After the focus group, participant confidence in instructing lay providers on proper tourniquet use significantly increased. Adding key steps, contextual pictures, and indicators of success to instructions could support lay providers stop the bleed in life-threatening situations.

In the wake of the September 11, 2001, attacks and the subsequent anthrax scare, there is growing concern about the United States' vulnerability to terrorist use of Weapons of Mass Destruction (WMD). As part of ongoing preparation for this terrible reality, many jurisdictions have been conducting simulated terrorist incidents to provide training for the public safety community, hospitals, and public health departments. As an example of this national effort to improve domestic preparedness for such events, a large scale, multi-jurisdictional chemical weapons drill was conducted in Cincinnati, Ohio, on May 20, 2000. This drill depicted the components of the early warning system for hospitals and public health departments, the prehospital medical response to terrorism. Over the course of the exercise, emergency medical services personnel decontaminated, triaged, treated, and transported eighty-five patients. Several important lessons were learned that day that have widespread applicability to health care delivery systems nationwide, especially in the areas of decontamination, triage, on-scene medical care, and victim transportation. As this training exercise helped Cincinnati to prepare for dealing with future large scale WMD incidents, such drills are invaluable preparation for all communities in a world increasingly at risk from terrorist attacks.