Paramedic versus emergency physician emergency medical service: Role of the anaesthesiologist and the European versus the Anglo-American concept

Current Opinion in Anaesthesiology

Volumn 21, Issue 2, 2008, Pages 222-227

  Timmermann, Arnd ^a   Russo, Sebastian G ^a   Hollmann, Markus W ^a,b  

^a UNIVERSITY OF GÖTTINGEN   (Germany)

^b ACADEMIC MEDICAL CENTER   (Netherlands)

Author keywords

Anaesthesiologist; Emergency medical service; Emergency physician; Outcome; Paramedic

Indexed keywords

ANESTHESIST; BLUNT TRAUMA; EMERGENCY CARE; EMERGENCY HEALTH SERVICE; EMERGENCY PHYSICIAN; ENDOTRACHEAL INTUBATION; FLUID RESUSCITATION; HEART ARREST; HEART INFARCTION; HUMAN; OXYGENATION; PARAMEDICAL PERSONNEL; PATIENT SAFETY; PRIORITY JOURNAL; RESPIRATORY FAILURE; RESUSCITATION; REVIEW; TRAUMATIC BRAIN INJURY; ANESTHESIOLOGY; COMPARATIVE STUDY; EUROPE; ORGANIZATION AND MANAGEMENT; PHYSICIAN ATTITUDE; UNITED STATES;

ALLIED HEALTH PERSONNEL; ANESTHESIOLOGY; EMERGENCY MEDICAL SERVICES; EUROPE; HUMANS; INTUBATION, INTRATRACHEAL; PHYSICIAN'S ROLE; UNITED STATES;

EID: 43249097095     PISSN: 09527907     EISSN: None     Source Type: Journal    
DOI: 10.1097/ACO.0b013e3282f5f4f7     Document Type: Review

References (70)

1. Roudsari BS, Nathens AB, Cameron P, et al. International comparison of prehospital trauma care systems. Injury 2007; 38:993-1000.
2. In this multicentre trial, trauma patient outcome was compared within and between countries using a technician-based EMS and a physician-staffed EMS. Early trauma fatality rate was significantly lower in the physician-based EMS.
3. Roudsari BS, Nathens AB, Arreola-Risa C, et al. Emergency medical service (EMS) systems in developed and developing countries. Injury 2007; 38: 1001-1013.
4. Hotvedt R, Kristiansen IS, Forde OH, et al. Which groups of patients benefit from helicopter evacuation? Lancet 1996; 347:1362-1366.
5. Lossius HM, Soreide E, Hotvedt R, et al. Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained? Acta Anaesthesiol Scand 2002; 46:771-778.
6. Herlitz J, Bang A, Gunnarsson J, et al. Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20years in the community of Goteborg, Sweden. Heart 2003; 89:25-30.
7. Horsted TI, Rasmussen LS, Lippert FK, Nielsen SL Outcome of out-ofhospital cardiac arrest: why do physicians withhold resuscitation attempts? Resuscitation 2004; 63:287-293.
8. Schuttler J, Schmitz B, Bartsch AC, Fischer M. The efficiency of emergency therapy in patients with head-brain, multiple injury: quality assurance in emergency medicine. Anaesthesist 1995; 44:850-858.
9. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: 'scoop and run' saves lives. J Trauma 2007; 63:113-120.
10. This retrospective chart review addressed the role of prehospital healthcare personnel in the management of most critically injured penetrating trauma patients. Patients were divided according to their mode of transportation (paramedics versus police/bystander). Mortality was more than two times higher for paramedic-transported patients.
11. Thies KC, Nagele P. Advanced Trauma LifeSupport (R): a standard of care for Germany? No substantial improvement of care can be expected. Anaesthesist 2007; 56:1147-1154.
12. In this overview the authors discuss the applicability of the Advanced Trauma Life Support (R) (ATLS) guidelines on the team-orientated EMS system in Germany. Next to other issues of guideline-orientated prehospital care, they criticized the SOP on spine immobilization as being exaggerated and not appropriate for many injured patients.
13. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support. Resuscitation 2005; 67:213-247.
14. Nolan JP, Deakin CD, Soar J, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 4: Adult advanced life support. Resuscitation 2005; 67 (Suppl 1): S39-S86.
15. Timmermann A, Russo SG, Rosenblatt WH, et al. Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation. Br J Anaesth 2007; 99:286-291.
16. This prospective study reports the successful use of the intubating laryngeal mask airway (ILMA) during difficult out-of-hospital airway management. All patients with difficult to manage airways could be ventilated and intubated via this device. The ILMA was inserted by anaesthesia-trained EMS physicians after a limited training in patients with normal airways.
17. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma 2003; 54:444-453.
18. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma 2005; 58:933-939.
19. Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on outcomes of major trauma patients. J Trauma 2000; 48:643-648.
20. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000; 283:783-790.
21. Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely headinjured patients. J Trauma 2004; 57:1-8; discussion 8-10.
22. Tiah L, Wong E, Chen MF, Sadarangani SP. Should there be a change in the teaching of airway management in the medical school curriculum? Resuscitation 2005; 64:87-91.
23. Weksler N, Tarnopolski A, Klein M, et al. Insertion of the endotracheal tube, laryngeal mask airway and oesophageal-tracheal Combitube: a 6-month comparative prospective study of acquisition and retention skills by medical students. Eur J Anaesthesiol 2005; 22:337-340.
24. Adnet F, Jouriles NJ, LeToumelin P, et al. Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study. Ann Emerg Med 1998; 32:454-460.
25. Bulger EM, Copass MK, Maier RV, et al. An analysis of advanced prehospital airway management. J Emerg Med 2002; 23:183-189.
26. Jacobs LM, Berrizbeitia LD, Bennett B, Madigan C. Endotracheal intubation in the prehospital phase of emergency medical care. JAMA 1983; 250:2175-2177.
27. Pointer JE. Clinical characteristics of paramedics' performance of endotracheal intubation. J Emerg Med 1988; 6:505-509.
28. Spaite DW, Criss EA. Out-of-hospital rapid sequence intubation: are we helping or hurting our patients? Ann Emerg Med 2003; 42:729-730.
29. Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86:635-639.
30. Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98:23-27.
31. Johnston BD, Seitz SR, Wang HE. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Acad Emerg Med 2006; 13:1051-1055.
32. This interesting study reported six to 10 endotracheal intubation attempts during training of US paramedics in the OR. Reasons for these limited attempts were reported as competition with other healthcare students, the increasing OR use of laryngeal mask airways, and physicians' medicolegal concerns.
33. Sayre MR, Sakles JC, Mistler AF, et al. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med 1998; 31:228-233.
34. Stewart RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel: success rates and complications. Chest 1984; 85:341-345.
35. Timmermann A, Braun U, Panzer W, et al. Out-of-hospital airway management in northern Germany: physician-specific knowledge, procedures and equipment. Anaesthesist 2007; 56:328-334.
36. Rosenblatt WH, Murphy M. The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department. Ann Emerg Med 1999; 33:234-238.
37. Thierbach A, Piepho T, Wolcke B, et al. Prehospital emergency airway management procedures: success rates and complications. Anaesthesist 2004; 53:543-550.
38. Boyle MF, Hatton D, Sheets C. Surgical cricothyrotomy performed by air ambulance flight nurses: a 5-year experience. J Emerg Med 1 993; 11:41-45.
39. Fortune JB, Judkins DG, Scanzaroli D, et al. Efficacy of prehospital surgical cricothyrotomy in trauma patients. J Trauma 1997; 42:832-836; discussion 837-838.
40. Hawkins ML, Shapiro MB, Cue JI, Wiggins SS. Emergency cricothyrotomy: a reassessment. Am Surg 1995; 61:52-55.
41. Jacobson LE, Gomez GA, Sobieray RJ, et al. Surgical cricothyroidotomy in trauma patients: analysis of its use by paramedics in the field. J Trauma 1996; 41:15-20.
42. GerichTG, Schmidt U, Hubrich V, et al. Prehospital airway management in the acutely injured patient: the role of surgical cricothyrotomy revisited. J Trauma 1998; 45:312-314.
43. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001; 37: 32-37.
44. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med 2005; 45:497-503.
45. Timmermann A, Russo SG, Eich C, et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007; 104:619-623.
46. During a 5-year investigation, independent observers reported an incidence of 7% unrecognized esophageal intubations when ETI was attempted by EMS physicians. Unrecognized esophageal intubation was associated with a 70% mortality rate.
47. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007; 11:213-218.
48. The authors reported an incidence of unrecognized endotracheal tube misplacement of 9%, when ETI was performed out of hospital by paramedics. Tube placement was verified at arrival in the emergency room. Mortality associated with misplacement was 90%.
49. Timmermann A, Russo S, Crozier TC, et al. Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag mask ventilation and laryngoscopy. Anesthesiology 2007; 107:570-576.
50. Novices ventilate and intubate patients with no anticipated difficult airways more quickly and safely via ILMA than by conventional bag-mask ventilation and laryngoscopy. In addition, ILMA-guided ETI is usually successful in patients in whom laryngoscopic-guided ETI had failed. The authors conclude that training programs should be extended to include the ILMA for ventilation and intubation.
51. Garner A, Rashford S, Lee A, Bartolacci R. Addition of physicians to paramedic helicopter services decreases blunt trauma mortality. Aust N Z J Surg 1999; 69:697-701.
52. Osterwalder JJ. Mortality of blunt polytrauma: a comparison between emergency physicians and emergency medical technicians: prospective cohort study at a level I hospital in eastern Switzerland. J Trauma 2003; 55:355-361.
53. Frankema SP, Ringburg AN, Steyerberg EW, et al. Beneficial effect of helicopter emergency medical services on survival of severely injured patients. Br J Surg 2004; 91:1520-1526.
54. Klemen P, Grmec S. Effect of prehospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury. Acta Anaesthesiol Scand 2006; 50:1250-1254.
55. Chi JH, Knudson MM, Vassar MJ, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma 2006; 61:1134-1141.
56. This study determined the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with brain injuries. Evaluation of 150 patients revealed that secondary insults after traumatic brain injury are common and prehospital hypoxia significantly increased mortality.
57. Ringburg AN, Spanjersberg WR, Frankema SP, et al. Helicopter emergency medical services (HEMS): impact on on-scene times. J Trauma 2007; 63:258-262.
58. Hoyer CC, Christensen EF, Andersen NT. On-scene time in advanced trauma life support by anaesthesiologists. Eur J Emerg Med 2006; 13:156-159.
59. Iirola TT, Laaksonen MI, Vahlberg TJ, Palve HK. Effect of physician-staffed helicopter emergency medical service on blunt trauma patient survival and prehospital care. Eur J Emerg Med 2006; 13:335-339.
60. Retrospective analysis of 158 patients with blunt trauma treated either by physician-staffed HEMS or following load and go approach. Beneficial effects of treatment by physicians were not observed.
61. Sefrin P, Kuhnigk H. The position of the emergency physician in the emergency medical service. Anasthesiol Intensivmed Notfallmed Schmerzther 2006; 41:2-8.
62. Fischer M, Krep H, Wierich D, et al. Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzther 2003; 38:630-642.
63. Bottiger BW, Grabner C, Bauer H, et al. Long term outcome after out-of-hospital cardiac arrest with physician staffed emergency medical services: the Utstein style applied to a midsized urban/suburban area. Heart 1999; 82:674-679.
64. Estner HL, Gunzel C, Ndrepepa G, et al. Outcome after out-of-hospital cardiac arrest in a physician-staffed emergency medical system according to the Utstein style. Am Heart J 2007; 153:792-799.
65. McNamara RL, Herrin J, Wang Y, et al. Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction. Am J Cardiol 2007; 100:1227-1232.
66. Nallamothu B, Fox KA, Kennelly BM, et al. Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events. Heart 2007; 93:1552-1555.
67. Nallamothu BK, Bradley EH, Krumholz HM. Time to treatment in primary percutaneous coronary intervention. N Engl J Med 2007; 357:1631-1638.
68. Nallamothu BK, Bates ER, Herrin J, et al. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation 2005; 111:761-767.
69. van't Hof AW, Rasoul S, van de Wetering H, et al. Feasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction. Am Heart J 2006; 151:1255.e1-e5.
70. Welsh RC, Travers A, Senaratne M, et al. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006; 152:1007-1014.