Artículos de revistas sobre el tema "Emergency Medical Services (EMS)"
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Weaver, Matthew D., Charity G. Moore, P. Daniel Patterson y Donald M. Yealy. "Medical Necessity in Emergency Medical Services Transports". American Journal of Medical Quality 27, n.º 3 (27 de diciembre de 2011): 250–55. http://dx.doi.org/10.1177/1062860611424331.
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The purpose of this study was to generate national estimates of the prevalence of medically unnecessary emergency medical services (EMS) transports to emergency departments (EDs) over time and to identify characteristics that may be associated with medically unnecessary transports. A previously published algorithm was applied to operationalize medical necessity based on ED diagnosis to 10 years of data from the National Hospital Ambulatory Medical Care Survey. The trend over time was reported using descriptive statistics weighted to produce national estimates. Nationally, the proportion of EMS transports that were medically unnecessary increased from 13% to 17% over the 10-year study period. Individual demographic characteristics, including insurance status, were not predictive of inappropriate utilization. EMS transports for medically unnecessary complaints increased from 1997 to 2007. Our findings from a nationally representative sample highlight the opportunity for alternative patient delivery strategies for select patients seeking EMS services.
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Wijesekera, Olindi, Amanda Reed, Parker S. Chastain, Shauna Biggs, Elizabeth G. Clark, Tamorish Kole, Anoop T. Chakrapani et al. "Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments". Prehospital and Disaster Medicine 31, n.º 6 (19 de septiembre de 2016): 675–79. http://dx.doi.org/10.1017/s1049023x16000959.
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AbstractIntroductionWithout a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum.MethodsA retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review.ResultsA range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease.ConclusionsNeurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills.WijesekeraO, ReedA, ChastainPS, BiggsS, ClarkEG, KoleT, ChakrapaniAT, AshishN, RajhansP, BreaudAH, JacquetGA. Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675–679.
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Nguyễn, Tiến Dũng y Như Lâm Nguyễn. "Emergency medical services: Literature review." Tạp chí Y học Thảm hoạ và Bỏng, n.º 6 (26 de enero de 2022): 5–10. http://dx.doi.org/10.54804/yhthvb.6.2021.87.
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Emergency Medical Service (EMS) systems worldwide are complex systems, characterized by significant variation between countries, care pathways and quality care indicators. Therefore, analyzing and improving them is challenging. As the EMS systems differ between countries, it is difficult to provide generic rules and approaches for EMS planning. However, the common target of all countries is to offer medical assistance to patients/victims with serious injuries or illnesses in disaster/ mass casualty incidents as quickly as possible. This paper presents an overview of logistical problems arising for EMS providers.
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Clemency, Brian, Christian Martin-Gill, Nicole Rall, Dipesh Patel y Jeffery Myers. "US Emergency Medical Services Fellows". Prehospital and Disaster Medicine 33, n.º 3 (18 de abril de 2018): 339–41. http://dx.doi.org/10.1017/s1049023x18000249.
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AbstractIntroductionThe 2015-2016 academic year was the fourth year since the Accreditation Council for Graduate Medical Education (ACGME; Chicago, Illinois USA) accredited Emergency Medical Services (EMS) fellowships, and the first year an in-training examination was given. Soon, ACGME-accredited fellowship education will be the sole path to EMS board certification when the practice pathway closes after 2019. This project aimed to describe the current class of EMS fellows at ACGME-accredited programs and their current educational opportunities to better understand current and future needs in EMS fellowship education.MethodsThis was a cross-sectional survey of EMS fellows in ACGME-accredited programs in conjunction with the first EMS In-Training Examination (EMSITE) between April and June 2016. Fellows completed a 14-question survey composed of multiple-choice and free-response questions. Basic frequency statistics were performed on their responses.ResultsFifty fellows from 35 ACGME-accredited programs completed the survey. The response rate was 100%. Forty-eight (96%) fellows reported previous training in emergency medicine. Twenty (40%) were undergoing fellowship training at the same institution as their prior residency training. Twenty-five (50%) fellows performed direct patient care aboard a helicopter during their fellowship. Thirty-three (66%) fellows had a dedicated physician response vehicle for fellows. All fellows reported using the National Association of EMS Physicians (NAEMSP; Overland Park, Kansas USA) textbooks as their primary reference. Fellows felt most prepared for the Clinical Aspects questions and least prepared for Quality Management and Research questions on the board exam.ConclusionThese data provide insight into the characteristics of EMS fellows in ACGME-accredited programs.ClemencyB, Martin-GillC, RallN, PatelD, MyersJ. US Emergency Medical Services fellows. Prehosp Disaster Med. 2018;33(3):339–341.
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Reissman, Stephan G. "Privatization and Emergency Medical Services". Prehospital and Disaster Medicine 12, n.º 1 (marzo de 1997): 22–29. http://dx.doi.org/10.1017/s1049023x00037171.
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AbstractIntroduction:Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, “It is not government's obligation to provide services, but to see that they're provided.” Even in the area of public safety, privatization has found a “market.”In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9–1–1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this “contracting-out” model has many benefits.Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service.The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered.The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers.
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Lenjani, Basri, Merima Šišić, Verica Mišanović, Kenan Ljuhar y Dardan Lenjani. "Challenges and Problems Affecting the Development Emergency Medical Services in Kosovo." Albanian Journal of Trauma and Emergency Surgery 5, n.º 2 (20 de julio de 2021): 825–29. http://dx.doi.org/10.32391/ajtes.v5i2.245.
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Emergency medical service is organized as a separate field of health activities in order to provide uninterrupted emergency medical care for citizens who due to illness or injury have directly threatened the life, certain organs or certain parts of the body respectively cut the optimal time of occurrence of the emergency until the start of the final treatment process. Emergence clinic for 2020. Year ED over 100. 000-cases. The emergency health system doesn’t have a consolidated network and integrated emergency medical services. Emergency health services in Europe are being challenged by changes in life dynamics, scientific advancements, which do increase the request to further improve the way of delivering emergency services. Health-system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises, to maintain core functions when a crisis hits, and—informed by lessons learned during the crisis to reorganize if conditions require it. Emergency clinic today at UCCK offers an area of 507m2, with 22 beds in the living room (1 bed per 100,000 population). Compliance with the law on emergency medical care, support, and improvement of EMS creating a special budget for EMS. EMS Independence (Decentralization). Budget, Management, accreditation, initiation of a project of systematization doctors of nurses in an integrated system. Regulation of administrative and legal infrastructure for EMS. The increase in salary (during holidays, weekends), shortening working hours for EMS, beneficial path (stress, risk, complexity, infections, first contact with the patient), the extension of annual leave. Functionalization of the Permanent National Center for Education EMS training, licensing, relicensing (medical staff) Quality control or EMS quality.
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Krohmer, Jon R., Robert A. Swor, Nicholas Benson, Steven A. Meador y Steven J. Davidson. "Prototype Curriculum for a Fellowship in Emergency Medical Services". Prehospital and Disaster Medicine 9, n.º 1 (marzo de 1994): 73–77. http://dx.doi.org/10.1017/s1049023x00040899.
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The developments of emergency medicine and emergency medical services (EMS) have occurred simultaneously although at times on parallel paths. The recognition of EMS providers as physician surrogates and emergency care resources as an extension of emergency department care has mandated close physician involvement. This intimate physician involvement in EMS activities is now well accepted. It has, however, pointed out the need for in-depth training of physicians in the subspecialty of EMS.
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Nagel, Eugene. "Perspectives of Emergency Medical Services (EMS)". Prehospital and Disaster Medicine 1, S1 (1985): 111–14. http://dx.doi.org/10.1017/s1049023x00044034.
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Many of the world leaders in emergency medicine and in disaster medicine systems have made advances in these fields, and I compliment them on the accomplishments that I have seen over the years. Dr. Safar charged me to look ahead, if that is possible, and offer some perspective—obviously my own—on the next five to ten years. Hopefully, our future can be controlled in certain limits. Toynbee philosophized that when new and unanticipated challenges are presented, they represent great opportunity for response. If we fail to respond or if we respond in an inappropriate way, we may become a fossil in history—in this case, in the history of medicine. I have attempted to look at important challenges that I see in emergency medicine, and to predict from these a course that I think represents a proper response.The first challenge, one that you have heard of before, clearly is the most important one. It is the challenge of limited or relative resources. The term “relative” means that fraction of a country's or region's output or wherewithall that is available in a logical or rational way for emergency medicine.
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Jaklič, Tatjana Kitić, Jure Kovač, Matjaž Maletič y Ksenija Tušek Bunc. "Analysis of patient satisfaction with emergency medical services". Open Medicine 13, n.º 1 (22 de octubre de 2018): 493–502. http://dx.doi.org/10.1515/med-2018-0073.
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AbstractBackgroundThis study analyses the degree of patient satisfaction regarding the Emergency Medical Services (EMS) by taking into account the waiting time which is considered to be associated with the success of the EMS organizational model.MethodologyBetween 1 Jan 2016 and 31 March 2016 a cross-sectional research study among visitors of the EMS clinics in the EMS of the Primary Health Services of Gorenjska was performed. The EUROPEP survey was used for rating the degree of patient satisfaction. Statistical methods were utilized to determine the differences among the studied variables, namely the t test, one way ANOVA, as well as post-hoc multiple comparisons, were used.ResultsNearly all questions associated with the patient survey scored higher than 4.0, indicating patients were generally very satisfied with EMS treatment. Patients were least satisfied with the length of time spent waiting for an examination. The results showed that the waiting time is a statistically significant factor concerning all four dimensions of patient satisfaction: medical staff, clinical facilities, clinical equipment and organization of services (p < 0.05).ConclusionsResearch results have confirmed that the effectiveness of the EMS organizational model impacts on the degree of patient satisfaction. The research also revealed a deficiency in the current EMS organizational services at the prehospital level, given that triage frequently failed to be carried out upon a patient’s arrival at the EMS clinics.
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Dickinson, Edward T., Vincent P. Verdile, Timothy B. Duncan y Kerry A. Bryant. "56. Managed Care Organization Enrollee Utilization of 911 Emergency Medical Services". Prehospital and Disaster Medicine 11, S2 (septiembre de 1996): S34. http://dx.doi.org/10.1017/s1049023x00045738.
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Purpose: The accessibility of emergency medical services (EMS) for enrollees of managed care organizations (MCOs) is currently a topic of national debate. The mechanisms by which enrollees currently enter the EMS system have not been well described. The purpose of this study was to determine how these patients enter our EMS system.Methods: All enrollees who belong to the region's largest MCO and who were transported to hospital EDs by the paramedic level municipal EMS department were identified from billing records. Members of the MCO are mandated to call the MCO prior to seeking any emergency care. Dispatch logs were then examined to determine the time and origin of the call to the 911 communications center. Patient care records were used to obtain patient age, the level of care (ALS vs. BLS), and whether the ALS patient received medications (ALS Meds).Results: Over a six month period 195 enrollees were transported to EDs, Three modes of system entry were identified: Group I—enrollees who called 911 directly; Group II—enrollees who called the MCO triage center who then called 911 for the patient; and Group III—enrollees who were sent to the MCO center for evaluation and subsequently the MCO called 911 to transport the patient to the hospital.
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Leung, Kelvin Tak Yiu. "Promoting Continuing Professional Education and Research in Emergency Medical Services (EMS)". International Journal of Research and Engineering 4, n.º 12 (5 de enero de 2018): 303–3. http://dx.doi.org/10.21276/ijre.2018.5.1.3.
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Gemma, William. "The International Society of Emergency Medical Services (ISEMS)". Prehospital and Disaster Medicine 1, S1 (1985): 314. http://dx.doi.org/10.1017/s1049023x00044940.
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In September 1980 at the International Aeromedical Evacuation Congress held in Munich, West Germany, the International Society of Emergency Medical Services (ISEMS) was formed. The purpose of this new society is to develop, promote, and improve EMS throughout the world. The founding members came from sixteen nations and represented such regions as Africa, the Americas, Europe, and the Middle East.This new organization, ISEMS, provides a permanent, ongoing focal point for studies and serves as a global clearinghouse for EMS technical assistance, training, management, and evaluation. The Society remains on an international level, and its eligible membership consists of all persons who participate in EMS throughout the world. The publication of a scientific journal for all EMS personnel is planned. Through ISEMS, International Centers of Excellence will be established to provide technical assistance to countries for improvement of their EMS programs; training seminars and educational programs will also be sponsored. In addition, annually sponsored meetings in key cities in various countries of the world are planned.
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Blau, Gary y Susan A. Chapman. "Why do Emergency Medical Services (EMS) Professionals Leave EMS?" Prehospital and Disaster Medicine 31, S1 (diciembre de 2016): S105—S111. http://dx.doi.org/10.1017/s1049023x16001114.
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AbstractObjectiveThe objective was to determine why Emergency Medical Technician (EMT)-Basics and Paramedics leave the Emergency Medical Services (EMS) workforce.MethodsData were collected through annual surveys of nationally registered EMT-Basics and Paramedics from 1999 to 2008. Survey items dealing with satisfaction with the EMS profession, likelihood of leaving the profession, and likelihood of leaving their EMS job were assessed for both EMT-Basics and Paramedics, along with reasons for leaving the profession. Individuals whose responses indicated that they were not working in EMS were mailed a special exit survey to determine the reasons for leaving EMS.ResultsThe likelihood of leaving the profession in the next year was low for both EMT-Basics and Paramedics. Although overall satisfaction levels with the profession were high, EMT-Basics were significantly more satisfied than Paramedics. The most important reasons for leaving the profession were choosing to pursue further education and moving to a new location. A desire for better pay and benefits was a significantly more important reason for EMT-Paramedics’ exit decisions than for EMT-Basics.ConclusionsGiven the anticipated increased demand for EMS professionals in the next decade, continued study of issues associated with retention is strongly recommended. Some specific recommendations and suggestions for promoting retention are provided.BlauG, ChapmanSA. Why do Emergency Medical Services (EMS) professionals leave EMS?Prehosp Disaster Med. 2016;31(Suppl. 1):s105–s111.
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Tozija, Fimka y Nikola Jankulovski. "Strategy to Improve Quality in Emergency Medical Services: from Assessment to Policy". Archives of Industrial Hygiene and Toxicology 64, n.º 4 (1 de diciembre de 2013): 567–79. http://dx.doi.org/10.2478/10004-1254-64-2013-2337.
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AbstractThe aim of this paper was to present the strategic approach applied for improvement of quality in emergency medical services (EMS) in the Republic of Macedonia. This approach was accomplished through three stages: (I) assessment and recommendations for policies; (II) development of innovative evidence-based programmes; and (III) policy implementation. Strategic assessment of EMS was performed by applying WHO standard methodology. A survey was conducted in 2006/2007 on the national level in fifteen general hospitals, four university hospitals, and sixteen pre-hospital EMS. The overall evaluation was based on a hospital emergency department (ED) questionnaire, information on the general characteristics of the pre-hospital dispatch centre, review of ED medical records, and the patient questionnaire. The key findings of the assessment showed that EMS required extensive changes and improvements. Pre-hospital EMS was not well-developed and utilised. Hospital EDs were not organised as separate divisions ran by a head medical doctor. The diagnostic and treatment capacities were insufficient or outdated. Most of the surveyed hospitals were capable of providing essential diagnostic tests in 24 h or less. There was no follow-up of the EMS patients or an appropriate link between the hospital EDs and primary health care facilities. The main findings of the assessment, recommendations, and proposals for action served as the basis for new policies and integrated into Macedonia’s official strategy for emergency medical services 2009-2017.
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Nagel, Eugene. "Physician Leadership of Emergency Medical Services (EMS)". Prehospital and Disaster Medicine 1, S1 (1985): 115. http://dx.doi.org/10.1017/s1049023x00044046.
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I would hope that there is no question regarding the need for physician leadership in an EMS system; and that the question, if there is any, concerns the amount required, where it is to be applied, and its quality. EMS, I would remind you, stands for emergencymedicalservices. Medical delivery systems, in my opinion, require physicians for their design and implementation. That does not mean that all the services have to be delivered by physicians, but they need physician leadership.If this outlines the area of physician authority, then there is by definition a concomitant responsibility—authority without responsibility would be tyranny. The responsibility should provide an appropriate level of medical care that is current in concept, appropriate to the needs, considerate of the resources available, and coherent with the overall health care system. It must not be just an isolated EMS system.
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Harmer, Bryan, Melissa Ivey, John Hoyle, Jr. y Kieran Fogarty. "Examining Cognitive Aid Use in Emergency Medical Services". International Journal of Paramedicine, n.º 6 (3 de abril de 2024): 48–61. http://dx.doi.org/10.56068/jmrq7592.
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Background: Emergency Medical Service (EMS) clinicians render care in less than ideal environments, and errors occur at high rates. Some cognitive aids (CAs) have been shown to reduce errors and improve adherence to evidence-based practices. However, there have been no widespread studies examining CA use in EMS. The objective of this study was to examine the frequency of CA use by EMS clinicians and which clinicians were using them more frequently during patient care.
Methods: A cross-sectional online survey was developed using a modified Delphi method with items examining demographic information and the frequency that 15 selected CAs are used during patient care. A survey link was emailed to 136,093 EMS clinicians across six states (TX, ME, MI, LA, SC, and AR). Descriptive statistics were used to describe frequencies. Kruskal-Wallis was used to assess if use differed among demographic or employment groups, and Spearman correlation was used to examine the relationship between clinician age and CA use.
Results: A total of 2,251 respondents were included in the study after meeting the inclusion criteria. Of the 15 CAs examined, the length-based tape was the most used (Med= 3.0, IQR: 1.0 – 4.0). Overall CA use was limited, with a median score of 1.67 (IQR: 1.07 – 2.27). The following groups reported more frequent use of CAs: females (Med= 1.87, IQR: 1.27-2.47), Hispanics (Med= 1.93, IQR: 1.33-2.67), Black/African Americans (Med= 2.00, IQR: 1.20-2.53), air medical clinicians (Med= 2.00, IQR: 1.60-2.40) and clinicians working in military settings (Med= 2.23, IQR: 1.80-2.80). A small negative correlation was identified with age (r = -0.06, p = .005).
Conclusions: Overall, CA use in EMS is limited. More effort is needed to increase their use in EMS. This data may provide insight to better target areas of need, improve design, and improve implementation of CAs in EMS.
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Gage, Caleb Hanson, Charnelle Stander, Liz Gwyther y Willem Stassen. "Emergency medical services and palliative care: a scoping review". BMJ Open 13, n.º 3 (marzo de 2023): e071116. http://dx.doi.org/10.1136/bmjopen-2022-071116.
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ObjectivesThe aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present?DesignA scoping review of literature was performed with an a priori search strategy.Data sourcesMEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched.Eligibility criteria for selecting studiesEmpirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included.Data extraction and synthesisTwo independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines.ResultsIn total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS’ palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration.ConclusionEMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.
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Leggio, William J. y Kenneth J. D'Alessandro. "Support for Interdisciplinary Approaches in Emergency Medical Services Education". Creighton Journal of Interdisciplinary Leadership 1, n.º 1 (15 de mayo de 2015): 60. http://dx.doi.org/10.17062/cjil.v1i1.11.
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<p>This article analyzes the need for Emergency Medical Services (EMS) educational programs and academicians to develop interdisciplinary educational and training opportunities with other healthcare disciplines. A literature review was conducted on EMS education and interdisciplinary approaches in healthcare education. In general, support for both didactic and simulated interdisciplinary education in healthcare is supported by positive impacts on student learning and improved patient outcomes. Support for interdisciplinary approaches in EMS education was constructed by applying research on interdisciplinary healthcare education to the identified criticisms of EMS education. A critical analysis of the literature allowed for recommendations to be made on the implementation of and further research for interdisciplinary approaches in EMS education. This article supports EMS students to be educated in a way that is reflective of a profession that must work collaboratively to provide out-of-hospital healthcare. </p>
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Cook, Richard T. "The Institute of Medicine Report on Emergency Medical Services for Chi: Thoughts for Emergency Medical Technicians, Paramedics, and Emergency Physicians". Pediatrics 96, n.º 1 (1 de julio de 1995): 199–205. http://dx.doi.org/10.1542/peds.96.1.199.
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The emergency medical technician, the paramedic, and the emergency physician, as well as emergency physicians who have additional expertise in emergency medical service (EMS) prehospital care or pediatric emergency medicine (through experience or formal fellowship training), will all find the Institute of Medicine's report, Emergency Medical Services for Chi (EMS-C), to be an invaluable background resource as well as a guide for EMS system and EMS-C-related planning. With both breadth and depth, it reviews many of the issues in EMS-C today from many perspectives and provides practical information to enable these care givers to understand better the "big picture" of EMS-C as well as to assist them in continuing to make a difference in the day-to-day emergency care for children. It is well referenced, engenders respect for all members of the team within the broad continuum of EMS-C, and provides encouragement to them to work together to identify and address issues and solve problems to improve the quality of care for our nation's children.
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He, Zhaoxiang, Xiao Qin, Yuanchang Xie y Jianhua Guo. "Service Location Optimization Model for Improving Rural Emergency Medical Services". Transportation Research Record: Journal of the Transportation Research Board 2672, n.º 32 (12 de agosto de 2018): 83–93. http://dx.doi.org/10.1177/0361198118791363.
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Approximately 35,000 fatalities are attributed to accidents on U.S. highways each year and more than half of them occurred in rural areas. With such a high percentage of fatalities, rural areas are in critical need of timely and reliable Emergency Medical Services (EMS). EMS provide important prehospital care to victims before they are transferred to a hospital. After an accident occurs, the time it takes for victims to receive care from EMS is crucial to their survival. Compared with urban EMS, rural EMS face multiple challenges. One of them is how to properly site EMS stations to provide cost-effective services in rural areas. The goals of this paper include analyzing the spatial patterns of EMS station and incident locations, and optimizing rural EMS station locations. The data were collected from South Dakota, a rural state. This dataset was used to perform spatial analysis and to develop and evaluate an EMS location optimization model. The location optimization model aims to maximize the rural EMS coverage while taking service equity into consideration. The model was solved by a genetic algorithm toolbox in R. The proposed model provides an important and practical tool for rural EMS officials to select new EMS stations or relocate existing stations to improve service performance under budget and resource constraints.
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Sharma, Mohit y Ethan S. Brandler. "Emergency Medical Services in India: The Present and Future". Prehospital and Disaster Medicine 29, n.º 3 (10 de abril de 2014): 307–10. http://dx.doi.org/10.1017/s1049023x14000296.
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AbstractIndia is the second most populous country in the world. Currently, India does not have a centralized body which provides guidelines for training and operation of Emergency Medical Services (EMS). Emergency Medical Services are fragmented and not accessible throughout the country. Most people do not know the number to call in case of an emergency; services such as Dial 108/102/1298 Ambulances, Centralized Accident and Trauma Service (CATS), and private ambulance models exist with wide variability in their dispatch and transport capabilities. Variability also exists in EMS education standards with the recent establishment of courses like Emergency Medical Technician-Basic/Advanced, Paramedic, Prehospital Trauma Technician, Diploma Trauma Technician, and Postgraduate Diploma in EMS. This report highlights recommendations that have been put forth to help optimize the Indian prehospital emergency care system, including regionalization of EMS, better training opportunities, budgetary provisions, and improving awareness among the general community. The importance of public and private partnerships in implementing an organized prehospital care system in India discussed in the report may be a reasonable solution for improved EMS in other developing countries.SharmaM, BrandlerES. Emergency Medical Services in India: the present and future. Prehosp Disaster Med. 2014;29(3):1-4.
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Long, Brit J., Luis A. Serrano, Jose G. Cabanas y M. Fernanda Bellolio. "Opportunities for Emergency Medical Services (EMS) Care of Syncope". Prehospital and Disaster Medicine 31, n.º 4 (23 de mayo de 2016): 349–52. http://dx.doi.org/10.1017/s1049023x16000376.
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AbstractIntroductionEmergency Medical Service (EMS) systems are vital in the identification, assessment, and treatment of trauma, stroke, myocardial infarction, and sepsis patients, improving early recognition, resuscitation, and transport. Emergency Medical Service personnel provide similar care for patients with syncope. The role of EMS in the management of patients with syncope has not been reported.Hypothesis/ObjectiveThe objective of this study was to describe the management of out-of-hospital syncope by prehospital providers in an urban EMS system.MethodsThis was a retrospective cohort study of consecutively enrolled patients over 18 years of age, over a two-year period, who presented by EMS with syncope, or near-syncope, to a tertiary care emergency department (ED). Demographics included comorbidities, history, and physical exam findings documented by prehospital providers, as well as the interventions provided. Data were collected from standardized patient care records for descriptive analysis.ResultsOf the 723 patients presenting with syncope to the ED, 284 (39.3%) were transported by EMS. Compared to non-EMS patients, those who arrived by ambulance were older (mean age 65 [SD = 18.5] years versus 61 [SD = 19.2] years; P = .019). There were no statistically significant differences in cardiovascular comorbidities (hypertension, coronary artery disease, diabetes mellitus, stroke, or congestive heart failure) between EMS and non-EMS patients. The most common chief complaints were fainting (50.0%) and dizziness (44.7%). The most common intervention provided was cardiac monitoring (55.6%), followed by administration of normal saline infusion (50.5%), oxygen (41.9%), blood glucose check (41.5%), and electrocardiogram (EKG; 40.5%).ConclusionEmergency Medical Service personnel transport more than one-third of patients presenting to the ED with syncope. Documentation of key elements of the history (witnesses, prodrome, predisposing factors, and post-event symptoms) and physical examination were not recorded consistently.LongBJ, SerranoLA, CabanasJG, BellolioMF. Opportunities for Emergency Medical Services (EMS) care of syncope. Prehosp Disaster Med. 2016;31(4):349–352.
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Mould-Millman, Nee-Kofi, Julia M. Dixon, Nana Sefa, Arthur Yancey, Bonaventure G. Hollong, Mohamed Hagahmed, Adit A. Ginde y Lee A. Wallis. "The State of Emergency Medical Services (EMS) Systems in Africa". Prehospital and Disaster Medicine 32, n.º 3 (23 de febrero de 2017): 273–83. http://dx.doi.org/10.1017/s1049023x17000061.
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AbstractIntroductionLittle is known about the existence, distribution, and characteristics of Emergency Medical Services (EMS) systems in Africa, or the corresponding epidemiology of prehospital illness and injury.MethodsA survey was conducted between 2013 and 2014 by distributing a detailed EMS system questionnaire to experts in paper and electronic versions. The questionnaire ascertained EMS systems’ jurisdiction, operations, finance, clinical care, resources, and regulatory environment. The discovery of respondents with requisite expertise occurred in multiple phases, including snowball sampling, a review of published scientific literature, and a rigorous search of the Internet.ResultsThe survey response rate was 46%, and data represented 49 of 54 (91%) African countries. Twenty-five EMS systems were identified and distributed among 16 countries (30% of African countries). There was no evidence of EMS systems in 33 (61%) countries. A total of 98,574,731 (8.7%) of the African population were serviced by at least one EMS system in 2012. The leading causes of EMS transport were (in order of decreasing frequency): injury, obstetric, respiratory, cardiovascular, and gastrointestinal complaints. Nineteen percent of African countries had government-financed EMS systems and 26% had a toll-free public access telephone number. Basic emergency medical technicians (EMTs) and Basic Life Support (BLS)-equipped ambulances were the most common cadre of provider and ambulance level, respectively (84% each).ConclusionEmergency Medical Services systems exist in one-third of African countries. Injury and obstetric complaints are the leading African prehospital conditions. Only a minority (<9.0%) of Africans have coverage by an EMS system. Most systems were predominantly BLS, government operated, and fee-for-service.Mould-MillmanNK, DixonJM, SefaN, YanceyA, HollongBG, HagahmedM, GindeAA, WallisLA. The state of Emergency Medical Services (EMS) systems in Africa. Prehosp Disaster Med. 2017;32(3):273–283.
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Furbee, Paul M., Jeffery H. Coben, Sharon K. Smyth, William G. Manley, Daniel E. Summers, Nels D. Sanddal, Teri L. Sanddal et al. "Realities of Rural Emergency Medical Services Disaster Preparedness". Prehospital and Disaster Medicine 21, n.º 2 (abril de 2006): 64–70. http://dx.doi.org/10.1017/s1049023x0000337x.
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AbstractIntroduction:Disaster preparedness is an area of major concern for the medical community that has been reinforced by recent world events. The emergency healthcare system must respond to all types of disasters, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored.Problem:This study sought to answer several questions, including: (1) What are rural emergency medical services (EMS) organizations training for, compared to what they actually have seen during the last two years?; (2) What scale and types of events do they believe they are prepared to cope with?; and (3) What do they feel are priority areas for training and preparedness?Methods:Data were gathered through a multi-region survey of 1,801 EMS organizations in the US to describe EMS response experiences during specific incidents as well as the frequency with which these events occur. Respondents were asked a number of questions about local priorities.Results:A total of 768 completed surveys were returned (43%). Over the past few years, training for commonly occurring types of crises and emergencies has declined in favor of terrorism preparedness. Many rural EMS organizations reported that events with 10 or fewer victims would overload them. Low priority was placed on interacting with other non-EMS disaster response agencies, and high priority was placed on basic staff training and retention.Conclusion:Maintaining viable, rural, emergency response capabilities and developing a community-wide response to natural or man-made events is crucial to mitigate long-term effects of disasters on a local healthcare system. The assessment of preparedness activities accomplished in this study will help to identify common themes to better prioritize preparedness activities and maximize the response capabilities of an EMS organization.
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Chermiti, Ines, Mokhtar Mahjoubi, Hanene Ghazali, Camillia Jeddi, Morsi Ellouz, Syrine Keskes, Héla Ben Turkia y Sami Souissi. "Emergency Medical Services Response: Outcomes of Non-Transported Patients". Prehospital and Disaster Medicine 38, S1 (mayo de 2023): s38—s39. http://dx.doi.org/10.1017/s1049023x23001383.
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Introduction:As a part of a primary intervention, Emergency Medical Services (EMS) may leave a patient at the scene. This decision is made in partnership with the dispatching center. The prognosis of these patients is often unknown. The aim of our study was to assess the outcomes of non-transported EMS patients.Method:It was a descriptive, prospective study conducted over a two-year-period. We included all alive non-transported EMS patients from the site of intervention after a primary mission of the EMS team based on a medical decision. The prognosis was assessed by unexpected events (UE) defined by death, second EMS call, urgent consultation or hospitalization/surgery within seven days. We considered two groups: a group with UME (UME+) and a group with good evolution (UE-).Results:We included 97 patients. The average age was 56±19 years. Seventeen patients (17,5%) had no medical histories. Hypoglycemia was observed in 43% of patients. Thirty-four patients (35%) had an UE. These UEs were distributed as the following: ten consulted a private doctor, ten consulted their family physician, seven called the EMS, three visited the emergency department and four died. There were no significant differences in demographic, anamnestic characteristics between two groups. Psychiatric pathology was more common in the UE- group(28% vs. 9%; p=0.0037). Intravenous injections were more common in the UE+ group (64% vs 39% ; p=0,019). Among the four deaths, three were unexpected.Conclusion:One-third of non-transported EMS patients had UE. Unexpected death was rare (one patient). Setting-up a system for these patients including scores and algorithms, and a post-EMS compulsory visit in collaboration with family physicians could be beneficial.
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Apiratwarakul, Korakot, Ismet Celebi, Somsak Tiamkao, Vajarabhongsa Bhudhisawasdi, Chatkhane Pearkao y Kamonwon Ienghong. "Understanding of Development Emergency Medical Services in Laos Emergency Medicine Residents". Open Access Macedonian Journal of Medical Sciences 9, E (12 de noviembre de 2021): 1085–91. http://dx.doi.org/10.3889/oamjms.2021.7333.
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BACKGROUND: Rising death tolls from traffic accidents are quickly becoming an inescapable problem in almost all countries around the world. That being said, the World Health Organization has launched an ambitious campaign aimed at reducing the death rate from traffic accidents by 50% in the next 10 years. Development of emergency medical services (EMSs) was the tool to success the goals, especially in low- to middle-income countries including Laos. However, no studies regard perspective of training EMS in Laos emergency medicine residents. AIM: The aim of our work is to demonstrate the effect of EMS training for Laos emergency medicine residents to the development of the national policy in Lao’s EMS. METHODS: A cross-sectional study was conducted in two countries (Laos and Thailand) from January 2020. The project activities were establishment of a command-and-control center, development of EMS support system, and training for emergency care professionals. RESULTS: The eight Laos emergency medicine residents were enrolled between January and March 2020. After practicing as a dispatcher and emergency medical consultant in Thailand at Khon Kaen University, the participants from Laos found that all personnel gained experience and improved their knowledge of technology in EMS and organization management. This had a direct impact on improving confidence in their return to practice in Laos. CONCLUSIONS: The human resource development through international collaboration between Thailand and Laos is contributing the effective knowledge and expertise learning in Laos. Moreover, the result of this training may provide the most effective care system resulting in the much-needed drop in the mortality rate of traffic accidents in Laos.
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Leeies, Murdoch, Cheryl ffrench, Trevor Strome, Erin Weldon, Michael Bullard y Rob Grierson. "Prehospital Application of the Canadian Triage and Acuity Scale by Emergency Medical Services". CJEM 19, n.º 1 (10 de agosto de 2016): 26–31. http://dx.doi.org/10.1017/cem.2016.345.
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AbstractObjectivesTriage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice.MethodsVariables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTASarrival) score was compared to the initial nursing CTAS score (CTASinitial) and the final nursing CTAS score (CTASfinal) incuding nursing overrides. Interrater reliability between ED CTASinitial and EMS CTASarrival scores was assessed. Interrater reliability between ED CTASfinal and EMS CTASarrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated.ResultsOur primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTASarrival and ED CTASinitial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTASarrival) score and the final ED triage CTAS score (CTASfinal) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466).ConclusionsInterrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.
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Ebrahimian, Abbasali, Hesam Seyedin, Roohangiz Jamshidi-Orak y Gholamreza Masoumi. "Exploring Factors Affecting Emergency Medical Services Staffs’ Decision about Transporting Medical Patients to Medical Facilities". Emergency Medicine International 2014 (2014): 1–8. http://dx.doi.org/10.1155/2014/215329.
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Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs’ decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: “degree of perceived risk in EMS staffs and their patients.” This theme consisted of two main categories: (1) patient’s condition’ and (2) the context of the EMS mission’. The patent’s condition category emerged from “physical health statuses,” “socioeconomic statuses,” and “cultural background” subcategories. The context of the EMS mission also emerged from two subcategories of “characteristics of the mission” and EMS staffs characteristics’. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients’ needs for transportation in a prehospital situation.
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Eslami AliAbadi, Hasan, Raheleh Rajabi y Fariba Asadi. "Burnout among emergency medical services (EMS) staff". Quarterly Journal of Nersing Management 5, n.º 3 (1 de enero de 2017): 62–70. http://dx.doi.org/10.29252/ijnv.5.3.4.62.
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Stewart, Ronald D. "Introduction to Emergency Medical Services (EMS) Organization". Prehospital and Disaster Medicine 1, S1 (1985): 109–10. http://dx.doi.org/10.1017/s1049023x00044022.
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Experience and history have taught us that much can be done for the sick and injured before such patients reach the hospital. From the legacy of the Good Samaritan to the modern day organization of emergency medical services, the immediate care of those stricken has undergone significant change in both philosophy and practice. While many prehospital care organizations with roots established deeply in the past still flourish, modern emergency care, in the new world at least, has developed rapidly only over the past ten years.In the United States, a concerted effort to improve the care of the wounded during the Civil War led to the introduction of the “flying ambulances” used earlier by Napoleon's Chief Surgeon, Larrey. Americans made significant contributions to acute care with the work of such noted men as Crile, with his form of external pneumatic counterpressure; Kouwenhoven, Knickerbocker and Jude at lohns Hopkins; Beck and the first reported defibrillation in a patient; Safar and his co-workers with the rediscovery of mouth-to-mouth; and many others.
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Sivaraman, Josie J., Scott K. Proescholdbell, David Ezzell y Meghan E. Shanahan. "Characterizing Opioid Overdoses Using Emergency Medical Services Data". Public Health Reports 136, n.º 1_suppl (noviembre de 2021): 62S—71S. http://dx.doi.org/10.1177/00333549211026802.
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Objectives Tracking nonfatal overdoses in the escalating opioid overdose epidemic is important but challenging. The objective of this study was to create an innovative case definition of opioid overdose in North Carolina emergency medical services (EMS) data, with flexible methodology for application to other states’ data. Methods This study used de-identified North Carolina EMS encounter data from 2010-2015 for patients aged >12 years to develop a case definition of opioid overdose using an expert knowledge, rule-based algorithm reflecting whether key variables identified drug use/poisoning or overdose or whether the patient received naloxone. We text mined EMS narratives and applied a machine-learning classification tree model to the text to predict cases of opioid overdose. We trained models on the basis of whether the chief concern identified opioid overdose. Results Using a random sample from the data, we found the positive predictive value of this case definition to be 90.0%, as compared with 82.7% using a previously published case definition. Using our case definition, the number of unresponsive opioid overdoses increased from 3412 in 2010 to 7194 in 2015. The corresponding monthly rate increased by a factor of 1.7 from January 2010 (3.0 per 1000 encounters; n = 261 encounters) to December 2015 (5.1 per 1000 encounters; n = 622 encounters). Among EMS responses for unresponsive opioid overdose, the prevalence of naloxone use was 83%. Conclusions This study demonstrates the potential for using machine learning in combination with a more traditional substantive knowledge algorithm-based approach to create a case definition for opioid overdose in EMS data.
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Karrasch, Sarah, Melissa Hitzler, Alexander Behnke, Visal Tumani, Iris-Tatjana Kolassa y Roberto Rojas. "Chronic and Traumatic Stress Among Emergency Medical Services Personnel". Zeitschrift für Klinische Psychologie und Psychotherapie 49, n.º 4 (octubre de 2020): 204–17. http://dx.doi.org/10.1026/1616-3443/a000600.
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Abstract. Background: Emergency medical services (EMS) personnel are frequently confronted with multiple stressful and potentially traumatic events as well as adverse working conditions. Objective: This narrative review provides an overview of the impact of adverse mission experiences and working conditions on the mental and physical health of EMS personnel. Methods: We summarize the empirical findings on prevalence rates as well as individual vulnerability factors and resilience. Results: EMS personnel show the highest prevalence rates of stress-related health problems among first responders. The article outlines prevention and intervention approaches that contribute to maintaining and improving the mental and physical health of EMS personnel. Conclusion: In the future, further evidence-based intervention measures should be developed to adequately support this professional group.
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Supples, Michael W., Madison K. Rivard, Rebecca E. Cash, Kirsten Chrzan, Ashish R. Panchal y Henderson D. McGinnis. "Barriers to Physical Activity Among Emergency Medical Services Professionals". Journal of Physical Activity and Health 18, n.º 3 (1 de marzo de 2021): 304–9. http://dx.doi.org/10.1123/jpah.2020-0305.
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Background: Emergency medical services (EMS) professionals demonstrate low adherence to physical activity guidelines and experience a high prevalence of obesity and incidence of injury. The authors investigate the barriers to participating in physical activity among EMS professionals. Methods: The EMS professionals employed by 15 North Carolina EMS agencies were surveyed with validated items. Multivariable logistic regression models were used to estimate the odds (odds ratio, 95% confidence interval) of not meeting physical activity guidelines for each barrier to being active, controlling for age, sex, body mass index category, race/ethnicity, certification and education level, and work hours. Results: A total of 1367 EMS professionals were invited to participate, and 359 complete responses were recorded. Half of the respondents (48.2%) met Centers for Disease Control and Prevention physical activity guidelines. According to standard body mass index categories, 55.9% were obese. There were increased odds of not meeting physical activity guidelines for the following barriers: lack of energy (5.32, 3.12–9.09), lack of willpower (4.31, 2.57–7.22), lack of time (3.55, 2.12–5.94), social influence (3.02, 1.66–5.48), and lack of resources (2.14, 1.12–4.11). The barriers of fear of injury and lack of skill were not associated with meeting physical activity guidelines. Conclusion: Half of EMS professionals did not meet physical activity guidelines, and the majority were obese. Significant associations exist between several modifiable barriers and not meeting physical activity guidelines.
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Venesoja, Anu, Maaret Castrén, Susanna Tella y Veronica Lindström. "Patients’ perceptions of safety in emergency medical services: an interview study". BMJ Open 10, n.º 10 (octubre de 2020): e037488. http://dx.doi.org/10.1136/bmjopen-2020-037488.
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BackgroundResearch on patient safety in emergency medical services (EMS) has mainly focused on the organisation’s and/or the EMS personnel’s perspective. Little is known about how patients perceive safety in EMS. This study aims to describe the patients’ experiences of their sense of safety in EMS.MethodsA qualitative design with individual interviews of EMS patients (n=21) and an inductive qualitative content analysis were used.ResultsPatients’ experiences of EMS personnel’s ability or inability to show or use their medical, technical and driving skills affected the patients’ sense of safety. When they perceived a lack of professionalism and knowledge among EMS personnel, they felt unsafe. Patients highlighted equality in the encounter, the quality of the information given by EMS personnel and the opportunity to participate in their care as important factors creating a sense of safety during the EMS encounter. Altogether, patients’ perceptions of safety in EMS were connected to their confidence in the EMS personnel.ConclusionsOverall, patients felt safe during their EMS encounter, but the EMS personnel’s professional competence alone is not enough for them to feel safe. Lack of communication or professionalism may compromise their sense of safety. Further work is needed to explore how patients’ perceptions of safety can be used in improving safety in EMS.
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Prakash, A. y R. Nagose. "(A285) Planning and Organization of Emergency Medical Services in Mumbai". Prehospital and Disaster Medicine 26, S1 (mayo de 2011): s96. http://dx.doi.org/10.1017/s1049023x11003025.
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In the past two decades, Mumbai has witnessed several mass-casualty incidents. Somehow, it seems that the city has missed some important lessons from these events. Mumbai has no formal structure for emergency medical services (EMS). Although EMS may seem to be a much-desired necessity, scholars have raised questions on the practicality and feasibility of having such a system in Mumbai. Factors such as population congestion, traffic volume, and lack of coordination among existing hospitals, the success of such a system in a city like Mumbai is jeopardized. In spite of having similar challenges in some other regions of the country, EMS systems (e.g., in Gujarat) have achieved substantial success. This paper deals with the planning and organization of EMS in Mumbai. It evaluates the performances of the existing EMS systems in other Indian cities. The paper also discusses the advantages of having such a system, particularly during the events such as disasters, accidents, acts of terrorism, etc. The paper also discusses the possible consequences of the absence of EMS, such as delayed ambulance dispatch, improper distribution of patients, overcrowding at certain hospitals thereby leading to poor triage, and several similar problems that can worsen a crisis. It studies the potential challenges for the establishment of such a system in Mumbai, and suggests a model for an effective EMS system for the city.
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Al-Otaibi, Ahmed M., Sultan M. Alghadeer, Yazed Sulaiman AlRuthia, Abdulmajeed Mobrad, Mohammed A. Alhallaf, Abdullah A. Alghamdi, Saqer M. Althunayyan y Nawaf A. Albaqami. "The characteristics and distribution of emergency medical services in Saudi Arabia". Annals of Saudi Medicine 43, n.º 2 (marzo de 2023): 63–69. http://dx.doi.org/10.5144/0256-4947.2023.63.
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BACKGROUND: Emergency medical services (EMS) play an essential role in treating and transporting patients to hospitals or between hospitals. EMS providers must be distributed wisely across all regions of the country to meet healthcare needs during normal times and disasters. No previous study has investigated the characteristics and distribution of the EMS workforce in Saudi Arabia. OBJECTIVES: Examine the characteristics and distribution of the EMS workforce in Saudi Arabia to identify gaps and areas in need of improvement. Also, explore the sociodemographic and educational characteristics of licensed EMS providers in Saudi Arabia. DESIGN: Cross-sectional SETTINGS: EMS in Saudi Arabia METHODS: We included all licensed EMS providers in Saudi Arabia as of 23 December 2020 who were registered in the Saudi Commission for Health Specialties (SCFHS) database. Sociodemographics, where they earned certification, and their job affiliations were collected and categorized. MAIN OUTCOME MEASURES: EMS workforce distribution, gender, and EMS provider-to-population ratio. SAMPLE SIZE: 18 336 EMS providers; 8812 (48.1%) with documented job affiliations. RESULTS: The EMS provider-to-population ratio is very low. In Saudi Arabia, in general, the ratio is 1:3871 (based on n=8812 providers), which is low compared to the 1:1400 ratio for Australian EMS provider-to-population, for example. That makes it a challenge for EMS providers to meet the population’s needs, especially in times of disaster. The low ratio may have contributed to the delayed response time in Saudi Arabia (13 minutes for critical cases) which does not meet the international standard response time (8 minutes maximum). Also, only 3.5% of the total EMS providers registered were females, and the clear majority of all EMS providers were technicians. CONCLUSIONS: The growth in the EMS workforce, including the recruitment of more females into the workforce and more EMS specialists compared to EMS technicians and health assistants, is critical to reaching a satisfactory EMS provider-to-population ratio. LIMITATIONS: Most noteworthy of the limitations of this research are the insufficient statistics describing EMS distribution in Saudi Arabia, the lack of previous studies on the research topic in Saudi Arabia, and job affiliation not accurately recorded in the SCFHS database. CONFLICT OF INTEREST: None.
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Glober, Nancy, Thomas Lardaro, Michael Supples, Mark Liao, Julia Vaizer, Gregory Faris, Paige Ostahowski, Daniel O'Donnell y Christopher Kao. "Assessing Provider Understanding of Interfacility Emergency Medical Services Transport". International Journal of Paramedicine, n.º 5 (5 de enero de 2024): 64–73. http://dx.doi.org/10.56068/tgxv9507.
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Background: Interfacility transfer between hospitals is an integral component of regional healthcare systems. The decisions referring providers make regarding emergency medical services (EMS) level of care and transport modality (ground versus air) can dramatically impact patient care, emergency departments' workflow, hospital length of stay, and EMS resource availability. Limited research has been done to assess understanding of interfacility transport by emergency medicine providers.
Methods: We developed six patient scenarios to test knowledge of level of care and mode of interfacility transfer. Seven board-certified EMS physicians determined the optimal answer to each patient scenario. We distributed a survey with the scenarios to regional healthcare partners via a database of persons who utilize or interface with interfacility transport services. We collected answers to the patient scenarios and provider characteristics (primary practice site, sex, age, specialty, years since graducation, provider degree, EMS training received). Descriptive statistics were performed and Fisher's exact tests described differences in correct answers as they varied by specialty (emergency medicine or other specialty), provider type (physician or advanced practice provider), and reported training in EMS level of care.
Results: Seventy-six emergency medicine providers responded, including 68 physicians and 8 advanced practice providers. The mean total score on the case scenarios was 66%, with scores ranging from 33% to 100%. The mean scores on questions testing level of care and transport modality were 67% and 70%, respectively. No significant difference was found in test scores between emergency medicine and other specialties (p=0.718) or provider level of training (p=0.799). Training in EMS level of care was correlated with higher scores on the transport modality questions (p=0.003) but not on the level of care questions (p=0.231).
Conclusion: Variability exists in the knowledge of providers on interfacility transport throughout the state. Emergency medicine providers could benefit from education on interfacility transfer resources.
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Challen, Kirsty y Darren Walter. "Physiological Scoring: An Aid to Emergency Medical Services Transport Decisions?" Prehospital and Disaster Medicine 25, n.º 4 (agosto de 2010): 320–23. http://dx.doi.org/10.1017/s1049023x00008268.
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AbstractIntroduction:Attendance at UK emergency departments is rising steadily despite the proliferation of alternative unscheduled care providers. Evidence is mixed on the willingness of emergency medical services (EMS) providers to decline to transport patients and the safety of incorporating such an option into EMS provision. Physiologically based Early Warning Scores are in use in many hospitals and emergency departments, but not yet have been proven to be of benefit in the prehospital arena.Hypothesis:The use of a physiological-social scoring system could safely identify patients calling EMS who might be diverted from the emergency department to an alternative, unscheduled, care provider.Methods:This was a retrospective, cohort study of patients with a presenting complaint of “shortness of breath” or “difficulty breathing” transported to the emergency department by EMS. Retrospective calculation of a physiologicalsocial score (PMEWS) based on first recorded data from EMS records was performed. Outcome measures of hospital admission and need for physiologically stabilizing treatment in the emergency department also were performed.Results:A total of 215 records were analyzed. One hundred thirty-nine (65%) patients were admitted from the emergency department or received physiologically stabilizing treatment in the emergency department. Area Under the Receiver Operating Characteristic Curve (AUROC) for hospital admission was 0.697 and for admission or physiologically stabilizing treatment was 0.710. No patient scoring <2 was admitted or received stabilizing treatment.Conclusions:Despite significant over-triage, this system could have diverted 79 patients safely from the emergency department to alternative, unscheduled, care providers.
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Becker, Torben K., Marianne Gausche-Hill, Andrew L. Aswegan, Eileen F. Baker, Kelly J. Bookman, Richard N. Bradley, Robert A. De Lorenzo y David J. Schoenwetter. "Ethical Challenges in Emergency Medical Services: Controversies and Recommendations". Prehospital and Disaster Medicine 28, n.º 5 (26 de julio de 2013): 488–97. http://dx.doi.org/10.1017/s1049023x13008728.
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AbstractEmergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):1-10.
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Maguire, Brian J., Stephen Dean, Richard A. Bissell, Bruce J. Walz y Andrew K. Bumbak. "Epidemic and Bioterrorism Preparation among Emergency Medical Services Systems". Prehospital and Disaster Medicine 22, n.º 3 (junio de 2007): 237–42. http://dx.doi.org/10.1017/s1049023x0000474x.
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AbstractIntroduction:The purpose of this research was to determine the preparedness of emergency medical services (EMS) agencies in one US state to cope with a massive epidemic event.Methods:Data were collected primarily through telephone interviews with EMS officials throughout the State. To provide a comparison, nine out-ofstate emergency services agencies were invited to participate.Results:Emergency medical services agencies from nine of the 23 counties (39%) provided responses to some or all of the questions in the telephone survey. Seven of the nine out-of-state agencies provided responses to the survey. Most of the EMS agencies do not have broad, formal plans for response to large-scale bio-terrorist or pandemic events.Conclusions:The findings indicate that EMS agencies in this state fundamentally are unprepared for a large-scale bioterrorism or pandemic event.The few existing plans rely heavily on mutual aid from agencies that may be incapable of providing such aid. Therefore, EMS agencies must be prepared to manage a response to these incidents without assistance from any agencies outside of their local community. In order to accomplish this, they must begin planning and develop close working relationships with public health, healthcare, and elected officials within their local communities.
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El Sayed, Mazen, Hani Tamim, Ahel Al-Hajj Chehadeh y Amin A. Kazzi. "Emergency Medical Services Utilization in EMS Priority Conditions in Beirut, Lebanon". Prehospital and Disaster Medicine 31, n.º 6 (19 de septiembre de 2016): 621–27. http://dx.doi.org/10.1017/s1049023x16000972.
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AbstractBackgroundEarly activation and use of Emergency Medical Services (EMS) are associated with improved patient outcomes in EMS priority conditions in developed EMS systems. This study describes patterns of EMS use and identifies predictors of EMS utilization in EMS priority conditions in LebanonMethodsThis was a cross-sectional study of a random sample of adult patients presenting to the emergency department (ED) of a tertiary care center in Beirut with the following EMS priority conditions: chest pain, major trauma, respiratory distress, cardiac arrest, respiratory arrest, and airway obstruction. Patient/proxy survey (20 questions) and chart review were completed. The responses to survey questions were “disagree,” “neutral,” or “agree” and were scored as one, two, or three with three corresponding to higher likelihood of EMS use. A total scale score ranging from 20 to 60 was created and transformed from 0% to 100%. Data were analyzed based on mode of presentation (EMS vs other).ResultsAmong the 481 patients enrolled, only 112 (23.3%) used EMS. Mean age for study population was 63.7 years (SD=18.8 years) with 56.5% males. Mean clinical severity score (Emergency Severity Index [ESI]) was 2.5 (SD=0.7) and mean pain score was 3.1 (SD=3.5) at ED presentation. Over one-half (58.8%) needed admission to hospital with 21.8% to an intensive care unit care level and with a mortality rate of 7.3%. Significant associations were found between EMS use and the following variables: severity of illness, degree of pain, familiarity with EMS activation, previous EMS use, perceived EMS benefit, availability of EMS services, trust in EMS response times and treatment, advice from family, and unavailability of immediate private mode of transport (P≤.05). Functional screening, or requiring full assistance (OR=4.77; 95% CI, 1.85-12.29); acute symptoms onset ≤ one hour (OR=2.14; 95% CI, 1.08-4.26); and higher scale scores (OR=2.99; 95% CI, 2.20-4.07) were significant predictors of EMS use. Patients with lower clinical severity (OR=0.53; 95% CI, 0.35-0.81) and those with chest pain (OR=0.05; 95% CI, 0.02-0.12) or respiratory distress (OR=0.15; 95% CI, 0.07-0.31) using cardiac arrest as a reference were less likely to use EMS.ConclusionEmergency Medical Services use in EMS priority conditions in Lebanon is low. Several predictors of EMS use were identified. Emergency Medical Services initiatives addressing underutilization should result from this proposed assessment of the perspective of the EMS system’s end user.El SayedM, TamimH, Al-Hajj ChehadehA, KazziAA. Emergency Medical Services utilization in EMS priority conditions in Beirut, Lebanon. Prehosp Disaster Med. 2016;31(6):621–627.
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Yau, L., M. A. Mukarram, S. Kim, K. Arcot, K. Thavorn, M. Taljaard, M. Sivilotti, B. H. Rowe y V. Thiruganasambandamoorthy. "LO083: Outcomes and resource utilization among syncope patients transported by emergency medical services". CJEM 18, S1 (mayo de 2016): S58—S59. http://dx.doi.org/10.1017/cem.2016.120.
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Introduction: Syncope accounts for 1% of all annual emergency department (ED) visits in Canada with only 10.3% suffering serious adverse event (SAE) within 30-days. However, 66% are transported to ED by Emergency Medical Services (EMS). Our objectives were to assess 30 day SAE among syncope patients transported by Emergency medical services (EMS), assess the need to develop an EMS clinical decision aid, and estimate anticipated health care savings by diverting patients from the ED to alternative care pathways. Methods: We conducted a prospective cohort study at four tertiary care EDs from Feb 2012 to Feb 2013. We included patients ≥16 years of age with syncope and who arrived to the ED via EMS. We collected patient demographics, medical history, 30 day SAE, EMS time points (call received, EMS arrival on scene, EMS departure from scene, time of transfer of care in the ED), critical EMS interventions, and ED length of stay. We assessed for the occurrence of any SAE (death, arrhythmia, other cardiac and non-cardiac conditions) within 30 days of ED disposition. We used descriptive analysis, unpaired two-tailed t-test and chi-square test. Ethics approval was obtained at all study sites. Results: Of 1,475 ED patients with syncope during the study period, 992 (67.3%) arrived by EMS. Mean times (SD) for EMS arrival to the scene, patient assessment at the scene and transfer of patient from scene to the ED were 10.1 (6.4), 18.9 (8.3), and 14.6 (11.5) minutes respectively. Only two patients had critical interventions enroute (pacing and defibrillation). Overall 138 (13.9%) patients suffered a SAE; 32 (3.2%) detected by EMS, 58 (5.8%) detected during ED evaluation, 48 (4.8%) after ED disposition. The average ED length of stay was 5.9(4.2) hours. Based on average of cost from two sites, we estimated that total cost of transporting syncope patients from the scene to the ED to be $4 million in Canada. The total cost of ED care for syncope patients transported by EMS in Canada was calculated at $21.5 million. Conclusion: A substantial proportion of patients arriving to the ED via EMS suffer no SAE within 30 days. Correspondingly, our results suggest a need for an EMS clinical decision aid to divert low-risk syncope patients to alternative care pathways such as family physicians or rapid access clinics. If developed and implemented, this tool can potentially reduce EMS burden, ED crowding, and reduce healthcare costs.
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Munk, Marc-David. "Value Generation and Health Reform in Emergency Medical Services". Prehospital and Disaster Medicine 27, n.º 2 (abril de 2012): 111–14. http://dx.doi.org/10.1017/s1049023x12000635.
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AbstractAmerican Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.Munk MD. Value generation and health reform in emergency medical services. Prehosp Disaster Med. 2012;27(2):1-4.
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Crowe, Remle P., Roger Levine, Severo Rodriguez, Ashley D. Larrimore y Ronald G. Pirrallo. "Public Perception of Emergency Medical Services in the United States". Prehospital and Disaster Medicine 31, S1 (25 de noviembre de 2016): S112—S117. http://dx.doi.org/10.1017/s1049023x16001126.
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AbstractObjectiveThe objective of this study was to assess the public’s experience, expectations, and perceptions related to Emergency Medical Services (EMS).MethodsA population-based telephone interview of adults in the United States was conducted. The survey instrument consisted of 112 items. Demographic variables including age, race, political beliefs, and household income were collected. Data collection was performed by trained interviewers from Kent State University’s (Kent, Ohio USA)Social Research Laboratory. Descriptive statistics were calculated. Comparative analyses were conducted between those who used EMS at least once in the past five years and those who did not use EMS using χ2andttests.ResultsA total of 2,443 phone calls were made and 1,348 individuals agreed to complete the survey (55.2%). There were 297 individuals who requested to drop out of the survey during the phone interview, leaving a total of 1,051 (43.0%) full responses. Participants ranged in age from 18 to 94 years with an average age of 57.5 years. Most were Caucasian or white (83.0%), married (62.8%), and held conservative political beliefs (54.8%). Three-fourths of all respondents believed that at least 40% of patients survive cardiac arrest when EMS services are received. Over half (56.7%) believed that Emergency Medical Technician (EMT)-Basics and EMT-Paramedics provide the same level of care. The estimated median hours of training required for EMT-Basics was 100 hours (IQR: 40-200 hours), while the vast majority of respondents estimated that EMT-Paramedics are required to take fewer than 1,000 clock hours of training (99.3%). The majority believed EMS professionals should be screened for illegal drug use (97.0%), criminal background (95.9%), mental health (95.2%), and physical fitness (91.3%). Over one-third (37.6%) had used EMS within the past five years. Of these individuals, over two-thirds (69.6%) rated their most recent experience as “excellent.” More of those who used EMS at least once in the past five years reported a willingness to consent to participate in EMS research compared with those who had not used EMS (69.9% vs. 61.4%,P=.005).ConclusionsMost respondents who had used EMS services rated their experience as excellent. Nevertheless, expectations related to survival after cardiac arrest in the out-of-hospital setting were not realistic. Furthermore, much of the public was unaware of the differences in training hour requirements and level of care provided by EMT-Basics and EMT-Paramedics.CroweRP,LevineR,RodriguezS,LarrimoreAD,PirralloRG.Public perception of Emergency Medical Services in the United States.Prehosp Disaster Med.2016;31(Suppl.1):s112–s117.
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Roldan, Nidya Velasco, Caitlin E. Coyle, Michael Ward y Jan Mutchler. "IMPACT OF AGING POPULATIONS ON MUNICIPAL EMERGENCY MEDICAL SERVICES". Innovation in Aging 3, Supplement_1 (noviembre de 2019): S956. http://dx.doi.org/10.1093/geroni/igz038.3468.
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Abstract The services that residents require from their local governments vary depending on the demographics of their populations. While municipalities have long sought to consider how changes in the young population may impact their school system needs, few systematic considerations have been developed relating to how aging populations may impact municipal service provision. This study aims to address this issue by focusing on demands on emergency services at the municipal level. Using data from the Massachusetts Ambulance Trip Record Information System (MATRIS) we explore the association between emergency medical services (EMS) demand and population age-structure. The data shows an overrepresentation of older people among EMS users. People age 65 and older represent 16% of Massachusetts’ population but account for 31% of the transported emergent calls —e.g., 911 calls— and 60% of the scheduled transports. Results from the OLS regression analysis suggest that communities with larger shares of older residents have significantly higher numbers of EMS calls. The type of community and other age-related community features such as the percentage of older residents living alone and the percentage of older population dually eligible for Medicare and Medicaid are also significantly associated with the number of EMS calls. Contrary to our expectations, other resources available in the community such nursing homes or assisted living facilities were not significantly associated with number of EMS calls. Our research indicates that if growth in the older population occurs as projected, the demand placed on the EMS system by older populations will grow considerably in coming decades.
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Bardhan, Rupkatha y Traci Byrd. "Psychosocial Work Stress and Occupational Stressors in Emergency Medical Services". Healthcare 11, n.º 7 (29 de marzo de 2023): 976. http://dx.doi.org/10.3390/healthcare11070976.
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Emergency medical service (EMS) professionals often experience work stress, which escalated during COVID-19. High job demand in the EMS profession may lead to progressive decline in physical and mental health. We investigated the prevalence of psychosocial job stress in the three levels of EMS: basic, advanced, and paramedic, before and during the COVID-19 pandemic. EMS professionals (n = 36) were recruited from EMS agencies following the Institutional Review Board approval. Participants took surveys on demographics, personal characteristics, chronic diseases, and work schedules. Job stress indicators, namely the effort–reward ratio (ERR) and overcommitment (OC), were evaluated from survey questionnaires using the effort–reward imbalance model. Associations of job stress indicators with age, sex, body mass index, and working conditions were measured by logistic regression. Psychosocial work stress was prevalent with effort reward ratio > 1 in 83% of participants and overcommitment scores > 13 in 89% of participants. Age, body mass index, and work hours showed strong associations with ERR and OC scores. The investigation findings suggested that a psychosocial work environment is prevalent among EMS, as revealed by high ERR, OC, and their correlation with sleep apnea in rotating shift employees. Appropriate interventions may be helpful in reducing psychosocial work stress in EMS professionals.
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Kim, Sun Hyu y Hyeji Lee. "Characteristics of consecutive versus non-consecutive frequent emergency medical services transport to a single emergency department". PLOS ONE 19, n.º 5 (9 de mayo de 2024): e0301337. http://dx.doi.org/10.1371/journal.pone.0301337.
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Objective This study was to examine characteristics concerning frequent users of emergency medical services (EMS) transport by comparing patients who used EMS transport frequently for one year and those who used EMS transport for more than two years consecutively. Methods A retrospective review for frequent use of EMS transport was conducted. The patients from the fire stations that transported more than 70% of all EMS transport to the study hospital emergency department (ED) were included. The study subjects were divided into consecutive group (frequent EMS transport for ≥ two years consecutively) and non-consecutive group (frequent EMS transport for only one year). Characteristics of patients who were frequent users of EMS transport and those of all cases with EMS transport were examined. Results Of the total 205 patients and 1204 cases of frequent EMS transport, 85 (42%) patients and 755 (63%) cases were in the consecutive group. Patients in the consecutive group were more likely to have risky alcohol use, unemployed state, and medical aid type of payment for ED treatment than those in the non-consecutive group. More patients had previous experience of EMS transport to the study hospital ED in the consecutive group and the number of cases with alcohol ingestion was higher in the consecutive group. Elapsed time from EMS call to ED arrival was longer for the consecutive group. Conclusion Risky alcohol use, unemployed state, and previous experience of EMS transport were associated with consecutive and frequent use of EMS transport in frequent users of EMS transport.
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Brown, Lawrence H., N. Heramba Prasad y Kirk Grimmer. "Public Perceptions of a Rural Emergency Medical Services System". Prehospital and Disaster Medicine 9, n.º 4 (diciembre de 1994): 257–59. http://dx.doi.org/10.1017/s1049023x00041509.
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AbstractIntroduction:To determine the awareness of citizens and physicians concerning the capabilities of a rural emergency medical services (EMS) system.Hypothesis:Citizens and physicians are unaware of the capabilities of the EMS system.Methods:Residents were selected randomly from the local telephone directory and asked a series of structured questions about their EMS agency. A written survey was distributed to area physicians. Chi-square analysis was used to compare the proportion of respondents who knew the available interventions in their community with the proportion of those who did not. Statistical significance was inferred at p <0.01.Results:A total of 49% of the citizens were able to identify available skills, and 41.4% of the physicians were able to identify available skills. Physicians were less likely than were the citizens to be able to identify the skills performed by each provider (p <0.001).Conclusion:This study indicates that both physicians and the lay public have little understanding of the capabilities of their EMS system.
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Houser, Ryan. "Private Health Information Legal Protections in Emergency Medical Services". International Journal of Paramedicine, n.º 1 (16 de noviembre de 2022): 29–37. http://dx.doi.org/10.56068/jtng9057.
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Recent communications between counsel for an Emergency Medical Service (EMS) provider in New Jersey and the state Department of Health (DOH), Office of Emergency Medical Services (OEMS) claimed that the DOH was providing illicit access to private health information (PHI) based within the providers electronic patient care report (ePCR). While the response from the DOH indicated that the information sharing was completed in accordance with all state and federal laws, the concerns raised by the law firm are not novel concerns. EMS systems are often trusted by their patients to protect their PHI that is obtained as a necessity in the course of their lifesaving operations. The collection and use of data from EMS systems nationwide is crucial to the improvement of operations, provider safety, and patient care, however there is the competing interest of protecting the privacy of patients and respecting their Constitutionally protected rights. There are important legal and policy perspectives that should guide the prospect of personally identifiable EMS data sharing to law enforcement.
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Jaffe, David M. "Research in Emergency Medical Services for Chi". Pediatrics 96, n.º 1 (1 de julio de 1995): 191–94. http://dx.doi.org/10.1542/peds.96.1.191.
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Research is the key to future improvements in emergency medical services for chi (EMS-C). Ultimately these improvements should result in better prevention of childhood emergencies and better outcomes for children who experience emergency illness or injury. Research in EMS-C can be descriptive of the system and its users or focused on specific clinical or basic scientific questions. Descriptive research is needed to describe the EMS-C system, its users, the types of problems for which it is used, and the associated outcomes and costs. To facilitate the descriptive research, a uniform data set, a taxonomy of chief complaints, and a method of linkage among databases collected by different components of the system are needed. Focused research efforts in clinical and basic sciences are also needed. The Institute of Medicine report identified seven research areas for highest priority: clinical aspects of emergencies and emergency care; indices of severity of injury and, especially, seventy of illness; patient outcomes and outcome measures; costs; system organization, configuration, and operation; and effective approaches to education and training, and prevention. Maturity of the subspecialty of emergency medicine will be indicated by the development of basic science research and epidemiology by physicians with clinical interests in emergency medicine. The most exciting discoveries are likely to come in areas that we have not yet imagined. Rapid development of meaningful research will require massively increased funding to support both the research itself and the training of future scientists to work in pediatric emergency medicine.