This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians ...and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.
The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied ...guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.
Correspondence to Dr Ronald M Stewart, Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229, USA ; stewartr@uthscsa.edu ...Introduction Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) provides a new tool in selected patients for the management of non-compressible torso hemorrhage.1–3 Recent improvements in technology have facilitated more rapid placement through smaller femoral access sheaths, which may reduce access-related complications.4 However, high grade evidence to guide REBOA use is limited, and there is a substantial complication risk should this approach be used inappropriately.5 To address the current state of implementation of this new therapeutic strategy, the American College of Surgeons Committee on Trauma (ACS COT) has worked in collaboration with the American College of Emergency Physicians to issue this joint policy statement which addresses the current practice relevant to patient indications, potential complications, implementation, patient management, and training of providers. Acute care surgeons can learn and safely perform REBOA after a formal training course.9 REBOA is currently standard practice for select patients at a small number of trauma centers where surgeons are immediately available for the management of REBOA.2 6 The major rate-limiting step to REBOA is the ability to safely and efficiently cannulate the common femoral artery (CFA) in a hypovolemic patient.5 10–12 If percutaneous cannulation is not possible, surgical cut down is required. An acute care surgeon must be immediately available to definitively address the specific cause of hemorrhage to avert the dire complications of truncal and or spinal cord ischemia from prolonged aortic occlusion.10–12 Emergency medicine (EM) physicians with added certification in critical care (EMCC) trained in REBOA, may train and perform REBOA in conjunction with an acute care surgeon or vascular surgeon trained in REBOA, as long as the surgeon(s) is/are immediately available to definitively control the focused source of bleeding. Transfer of patients Due to the inability of prehospital providers to appropriately manage and troubleshoot the devices during transport, and the lack of evidence to support safe duration of aortic occlusion, transfer of patients with REBOA is not recommended. ...REBOA should not be placed in Emergency Departments in institutions where the patient cannot receive definitive surgical care and hemostasis at that same institution.
OBJECTIVES:In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH ...Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations.
METHODS:We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval).
RESULTS:We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to −0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92–0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites.
CONCLUSIONS:Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.
The Longitudinal Study of Emergency Medicine Residents (LSEMR) conducted by the American Board of Emergency Medicine queries a randomized cohort of emergency medicine (EM) residents. It is designed ...to identify residents’ perceptions of their training, sources of stress, well-being level, and career choice satisfaction over time.
This study utilizes LSEMR to identify resident well-being levels, career satisfaction, factors producing stress, and whether a specific cohort is more stressed than the overall respondent group.
Data from five longitudinal cohorts were analyzed using descriptive statistics to assess stressors, career satisfaction, and self-reported resident well-being. Participants’ answers were reported on a 5-point Likert scale.
There were 766 residents who completed the survey in five cohorts. Respondents were 30 years old (median 29), male (66%), and predominantly White (79%). The most frequently encountered problems included “time devoted to documentation and bureaucratic issues,” “knowing enough,” and “crowding in the emergency department.” In contrast, the least frequently reported problems included “gender discrimination,” “EMS support,” “minority discrimination,” and “other residents.” Respondents thought being an EM resident was fun and would select EM again. Less than 20% indicated they had seriously considered transferring to another EM program. Resident reports of health concerns changed over time, with fewer residents reporting they were exceptionally healthy in 2016.
Residents are, overall, happy with their career choice. However, concern was expressed regarding continued well-being in training. Sources of stress in training are identified. Strategies should be developed to decrease identified stressors and increase well-being among EM residents.
Abstract Introduction Frequent emergency department (ED) use has been identified as a cause of ED overcrowding and increasing health care costs. Studies have examined the expense of frequent patients ...(FPs) to hospitals but have not added the cost Emergency Medical Services (EMS) to estimate the total cost of this pattern of care. Methods Data on 2012 ED visits to a rural Level I Trauma Center and public safety net hospital were collected through a deidentified patient database. Transport data and 2012 Medicare Reimbursement Schedules were used to estimate the cost of EMS transport. Health information, outcomes, and costs were compared to find differences between the FP and non-FP group. Results This study identified 1242 FPs who visited the ED 5 or more times in 2012. Frequent patients comprised 3.25% of ED patients but accounted for 17% of ED visits and 13.7% of hospital costs. Frequent patients had higher rates of chronic disease, severity scores, and mortality. Frequent patients arrived more often via ambulance and accounted for 32% of total transports at an estimated cost of $2.5-$3.2 million. Hospital costs attributable to FPs were $29.1 million, bringing the total cost of emergency care to $31.6-$32.3 million, approximately $25,000 per patient. Conclusions This study demonstrates that the inclusion a prehospital cost estimate adds approximately 10% to the cost of care for the FP population. In addition to improving care for a sick population of patients, programs that reduce frequent EMS and ED use have the potential to produce a favorable cost benefit to communities and health systems.
The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National ...Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.
On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the ...subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.
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