Objective-The identification and treatment of critical illness is often initiated by emergency medical services (EMS) providers. We hypothesized that emergency department (ED) patients with severe sepsis who received EMS care had more rapid recognition and treatment compared with non-EMS patients.Methods-Prospective observational study of ED patients with severe sepsis treated with early goal-directed therapy (EGDT). We included adults with suspected infection, evidence of systemic inflammation, and either hypotension after a fluid bolus or elevated lactate. Prehospital and ED clinical variables and outcomes data were collected. The primary outcome was time to initiation of antibiotics in the ED.Results-There were 311 patients with 160 (51.4%) transported by EMS. EMS transported patients had more organ failure (sequential organ failure assessment score 7.0 vs. 6.1, p =0.02), shorter time to first antibiotics (111 vs. 146 minutes, p=0.001) and, shorter time from triage to EGDT initiation (119 vs. 160 minutes, p=0.005), compared to non-EMS transported patients. Among EMS patients, if the EMS provider indicated a written impression of sepsis, there was a shorter time to antibiotics (70 vs. 122 minutes, p=0.003) and a shorter time to EGDT initiation (69 vs. 131 minutes, p=0.001), compared to those without an impression of sepsis.Conclusions-In this prospective cohort, EMS provided initial care for half of severe sepsis patients requiring EGDT. Patients presented by EMS had more organ failure and a shorter time to both antibiotic and EGDT initiation in the ED.

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.

BackgroundUltrasound (US) vascular guidance is traditionally performed in transverse (T) and longitudinal (L) axes, each with drawbacks. We hypothesized that the introduction of a novel oblique (O) approach would improve the success of US-guided peripheral venous access. We examined emergency physician (EP) performance using the O approach in a gel US phantom.MethodsIn a prospective, case control study, EPs were enrolled from four levels of physician experience including postgraduate years one to three (PGY1, PGY2, PGY3) and attending physicians. After a brief training session, each participant attempted vessel aspiration using a linear probe in T, L, and O axes on a gel US phantom. Time to aspiration and number of attempts to aspiration were recorded. The approach order was randomized, and descriptive statistics were used.ResultsTwenty-four physicians participated. The first-attempt success rate was lower for O, 45.83%, versus 70.83% for T (p = 0.03) and 83.33% for L (p = 0.01). The average time to aspiration was 12.5 s (O) compared with 9.47 s (T) and 9.74 s (L), respectively. There were no significant differences between all four groups in regard to total amount of time and number of aspiration attempts; however, a trend appeared revealing that PGY3 and attending physicians tended to aspirate in less time and by fewer attempts in all three orientations when compared with the PGY2 and PGY1 physicians.ConclusionIn this pilot study, US-guided simulated peripheral venous access using a phantom gel model in a mixed user group showed that the novel oblique approach was not initially more successful versus T and L techniques.

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

For six months a survey was made of all the patients in the Nottingham District Health Authority who died or who were brought to hospital after a cardiac arrest outside hospital. During this period just under half of the emergency ambulance shifts were covered by specially trained crews with defibrillators. During the study period the ICD coding of death certificates indicated that 894 (25%) of the 3575 deaths were due to ischaemic heart disease. During this period the ambulance service received 17 749 emergency calls, which included 445 patients who had cardiac arrests outside hospital. One hundred and forty seven of these patients were carried by ambulances equipped with defibrillators and resuscitation was attempted in 83. Seven patients survived to leave hospital.The special ambulance service was cost effective-a simple calculation suggests that the cost per life saved was approximately £2600, but it seems unlikely that special ambulance services will materially affect community fatality rates from ischaemic heart disease.