Patients Who Refuse Transportation by Ambulance: A Case Series

1. Cook County Hospital, Chicago, Illinois, currently at Kaweah Delta District Hospital, Visalia, California USA

2.2. Sherman Hospital, GEA-MICP, Elgin, Illinois USA

3. School of Public Health, University of Illinois at Chicago, Chicago, Illinois USA

Correspondence: John E. Hipskind, MD Kaweah Delta District Hospital Department of Emergency Medicine 400 West Mineral King Avenue Visalia, CA 93277 USA E-mail: Johnfran@theworks.com

Key Words: COBRA; competency; complications; litigation; paramedics; prehospital; refusal; transportation

Abstract

Introduction: Patients refusing hospital transportation occurs in 5% to 25% of out-of-hospital calls. Little is known about these calls. This study was needed to determine the demographics, inherent risks, and timing of refused calls.

Methods: This was a prospective review of all run sheets of patients who refused transportation were collected for a two month period. Demographic data and medical information was collected. Each run was placed into one of three categories of need for transport and further evaluation: 1) minimal; 2) moderate; and 3) definite. The Greater Elgin Area Mobile Intensive Care Program (GEA-MICP) based at Sherman Hospital in Elgin, Illinois, was the setting. The GEA-MICP is an Emergency Medical Services (EMS) system comprised of 17 advanced life support (ALS) ambulance agencies servicing northeastern Illinois. Study subjects were all patients who refused transportation to a hospital by ALS ambulance during July 1993 and February 1994. Paramedics were required to complete a run sheet for all calls.

Results: Overall, 30% (683 of 2,270) of all runs resulted in refusal of transportation. Patients who most commonly refused transportation were asymptomatic, 11-40 years old and involved in a motor vehicle crash. They usually had no past medical history, normal vital signs, and a normal mental status. Patients generally signed for their own release after evaluation. The average time to arrival was 4.2 minutes and average time spent on scene by paramedics was 18.4 minutes. Of the patients, 72% were judged to have minimal need, 25% were felt to have a moderate need, and 3% were felt to definitely need transport to a hospital for further evaluation and/or treatment.

Conclusion: There are many cases when EMS are activated, but transportation is refused. Most refusals occur after paramedic evaluation. Providing paramedics with primary care training and protocols would standardize care given to patients and provide a mechanism for discharge instructions and follow-up for those who chose not to be transported to a hospital. Patients judged to require further treatment had unique characteristics. These data may be useful in identifying potentially sicker patients allowing a concentrated effort to transport this subset of patients to a hospital.

Hipskind JE, Gren JM, Barr DJ: Patients who refuse transportation by ambulance: A case series. Prehospital and Disaster Medicine 1997 12(4):278-283

Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?

AFFILIATION: Department of Emergency Medicine and Denver Paramedic Division, Denver Health Medical Center, Denver, Colorado, USA

REFERENCE: J Emerg Med 2002 May 23(1):43

Emergency Medical Services (EMS) agencies are increasingly being held to an ambulance response time (RT) criterion of responding to a medical emergency within 8 min for at least 90% of calls. This recommendation resulted from one study of outcome after nontraumatic cardiac arrest and has never been studied for any other emergency. This retrospective study evaluates the effect of exceeding the 8 min RT guideline on patient survival for victims of traumatic injury treated by an urban paramedic ambulance EMS system and transported to a single Level I trauma center. Of 3576 patients identified by the hospital trauma registry, 3490 (97.6%) had complete records available. Patients were grouped according to ambulance RT: 8 min ( n = 1040). After controlling for other significant predictors, there was no difference in survival after traumatic injury when the 8 min ambulance RT criteria was exceeded (mortality odds ratio 0.81, 95% CI 0. 43-1.52). There was also no significant difference in survival when patients were stratified by injury severity score group. Exceeding the ambulance industry response time criterion of 8 min does not affect patient survival after traumatic injury.

Prehospital selection of patients for thrombolysis by paramedics.

AFFILIATION: Welsh Ambulance Services NHS Trust, UK.

REFERENCE: Emerg Med J 2002 May 19(3):260-3

Objective: Heart disease is the major cause of death in Wales. Myocardial infarction accounts for most fatalities either acutely or as a result of late heart failure and unheralded sudden cardiac death. Prompt relief of new coronary occlusions by thrombolytic agents has been shown to reduce significantly both early mortality and subsequent morbidity from acute myocardial infarction. The prehospital delivery of these drugs is feasible, and carries no greater risk than administration in hospital. This study tests the hypothesis that paramedics can identify patients with acute myocardial infarction who are suitable for prehospital thrombolysis, and thus reduce the "call to needle" time.

Method: Paramedics from rural Wales were trained in the acquisition and recognition of 12 lead ECGs, and also in the modified indications for thrombolytic therapy as defined by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Ninety six consecutive patients, with possible myocardial infarction, were included in the study. The paramedics made an independent decision regarding the eligibility of the patients for thrombolysis before hospital admission, noting the time that they could have administered the drug. These decisions were compared with the treatment subsequently received in hospital. Results: No errors were made by the paramedics in case selection (specificity of 100% (95% CI 95.9% to 100%)). There was a potential reduction in call to needle time of 41.2 minutes (95% CI 25.7 minutes to 56.9 minutes, p=0.001).

Conclusions: It was concluded that the paramedic selection of patients for the prehospital administration of a thrombolytic is both feasible and safe.

Do paramedics make an effort not to transport at the end of their shifts?

OBJECTIVE: To determine if paramedics sign off more patients in the last hour of their shifts and if there is a correlation with the shifts' lengths.

METHODS: This was a retrospective study of EMS run report data derived from a computer aided dispatch (CAD) system. The last 200 eight-hour, 12-hour and 16-hour shifts (600 total shifts) in which there was at least one call for service in the last hour were reviewed. Transport/sign-off data were categorized and statistically analyzed.

RESULTS: There were not more patients signed off on any shift during the last hour. There was a statistically significantly smaller number of patients signed off in all phases of the eight-hour shifts.

CONCLUSION: Decreasing shift lengths to eight hours will significantly reduce the number of patient sign-offs and result in less potential liability.

Mobile Intensive Care Paramedics (MICPs)

OBJECTIVE: As the role of paramedics evolves, evaluation of their ability to accomplish an expanded scope of practice is necessary. The objective of this study was to determine whether specially trained paramedics can monitor and treat patients appropriately during interfacility transports that traditionally have required the use of supplemental, hospital-based personnel.

METHODS: A paramedic-staffed mobile intensive care unit was developed as a cooperative program between Huron Valley Ambulance and the Washtenaw/Livingston County Medical Control Authority. This prospective observational study involved 111 patients requiring interfacility transport, conveyed by a paramedic-staffed mobile intensive care unit. A change in the Acute Physiologic and Chronic Health Evaluation (APACHE II) score components of mean arterial pressure, heart rate, and respiratory rate at the beginning and end of the transport was used to evaluate the ability of the paramedics to accomplish the transfer appropriately.

RESULTS: APACHE II scores increased in 20 patients, decreased in 16, and were unchanged in 75. The mean value for the change in APACHE score was 0.11 (95% confidence interval: -0.11-0.33).

CONCLUSION: Specially trained paramedics can monitor and treat patients appropriately during interfacility transfers that traditionally would have required supplementation with additional hospital staff.

Hidden impact of paramedic interventions.

OBJECTIVE: To examine current patterns of deployment and use of emergency ambulance crews in Nottinghamshire, with particular reference to crew status (technician or paramedic), case mix, interventions performed, and operational times.

METHODS: A retrospective survey of routinely collected computerised ambulance service despatch data, and patient treatment forms for 242 randomly selected emergency callouts in Nottinghamshire, during September 1994. Data were collected on patient demography, broad diagnostic group, crew status and operational times, and paramedic interventions performed.

RESULTS: 170 of 242 callouts (70%) involved a paramedic crew; extended skills were used on 31 of these occasions (18%), predominantly for medical emergencies. Paramedic crews recorded significantly longer on-scene times (median time: 14.0 v 11.5 min, P = 0.04). An examination of the difference between paramedics who performed interventions and those who did not revealed that "intervening" paramedics recorded significantly longer onscene times (median time: 23 v 12 min, P < 0.001), turnaround times (median time: 28 v 18 min, P < 0.001), and total out-of-service times (median time 73 v 51 min, P < 0.001).

CONCLUSIONS: The additional time taken by paramedics at the scene of an emergency incident relates to their performance of an intervention, rather than time spent assessing the patient to decide whether stabilisation or immediate evacuation would be most appropriate. Paramedic interventions were most often performed for medical emergencies. The performance of paramedic interventions also extended turnaround times and total out-of-service times.

Once resolved, penicillin allergy does not redevelop with repeated courses

NEW YORK (Reuters Health) - Adults with a history of penicillin allergy that has resolved are not at increased risk of resensitization, results of a study released Sunday indicate. The authors say a single negative penicillin skin-test result allows these individuals to take multiple subsequent penicillin courses without a need for retesting. Dr. Roland Solensky at the Corvallis Center in Oregon and colleagues at the University of Texas Southwestern Medical Center at Dallas had a group of adults with a history of penicillin allergy undergo penicillin skin testing. Those testing negative were challenged with three successive 10-day courses of oral penicillin, if their skin test remained negative prior to each course.

As reported in the April 8th issue of Archives of Internal Medicine, 46 of 53 patients with initially negative skin tests completed the three-course protocol, with negative skin tests throughout. In comments to Reuters Health, Dr. Solensky said his team was "a little surprised that not one patient redeveloped their penicillin allergy. We expected the rate of resensitization to be relatively low, but not 0%."

"The vast majority of people labeled 'penicillin allergic' could take this class of antibiotics safely," Dr. Solensky said. "You would be surprised how many primary care physicians are not aware that penicillin skin testing even exists, although it has been available in its present form for about 30 years," he continued. "This is why we chose to publish the results in a general journal with a wide circulation, rather than an allergy specialty journal."

Dr. Solensky's team hopes that by increasing awareness of penicillin skin testing, fewer people will be falsely labeled as penicillin allergic, and this should lead to less over-utilization of broad-spectrum antibiotics, which contribute to antibiotic resistance. Arch Intern Med 2002;162:822-826.

TITLE: Prehospital selection of patients for thrombolysis by paramedics.

Objective: Heart disease is the major cause of death in Wales. Myocardial infarction accounts for most fatalities either acutely or as a result of late heart failure and unheralded sudden cardiac death. Prompt relief of new coronary occlusions by thrombolytic agents has been shown to reduce significantly both early mortality and subsequent morbidity from acute myocardial infarction. The prehospital delivery of these drugs is feasible, and carries no greater risk than administration in hospital. This study tests the hypothesis that paramedics can identify patients with acute myocardial infarction who are suitable for prehospital thrombolysis, and thus reduce the "call to needle" time.

Method: Paramedics from rural Wales were trained in the acquisition and recognition of 12 lead ECGs, and also in the modified indications for thrombolytic therapy as defined by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Ninety six consecutive patients, with possible myocardial infarction, were included in the study. The paramedics made an independent decision regarding the eligibility of the patients for thrombolysis before hospital admission, noting the time that they could have administered the drug. These decisions were compared with the treatment subsequently received in hospital. Results: No errors were made by the paramedics in case selection (specificity of 100% (95% CI 95.9% to 100%)). There was a potential reduction in call to needle time of 41.2 minutes (95% CI 25.7 minutes to 56.9 minutes, p=0.001).

Conclusions: It was concluded that the paramedic selection of patients for the prehospital administration of a thrombolytic is both feasible and safe.

Do ambulance crews with one advanced paramedic skills officer have longer scene times than crews with two?

Department of Emergency Medicine, Western Hospital, Footscray, Australia Metropolitan Ambulance Service, Melbourne, Australia.

REFERENCE: Emerg Med J 2002 Mar 19(2):152-4

Objective: In 1999, the Metropolitan Ambulance Service (MAS), Melbourne, Australia began implementing The Emergency Operations Plan (1998). One of the initiatives of the plan was the addition of crews with one advanced paramedic skills (APS) officer and one non-APS officer (mixed crews). All previous APS crews contained two APS officers working together. There was concern that mixed crews would have longer scene times than all-APS crews. This study aims to compare scene times at time critical cases for mixed crews and all-APS crews.

Methods: Prospective, non-randomised comparison of scene times for time critical cases for three mixed crew units and three all-APS units for the months of August to October 1999. The crew types were also compared by explicit retrospective audit for rates of APS procedures attempted and APS procedure failure rates. Data were analysed using SPSS, t test, and chi(2) test where appropriate. Results: There were 1700 time critical cases in the study period of which 1537 had valid data for the calculation of scene times. A total of 714 cases were attended by mixed crews and 823 cases by all-APS crews. The mean scene time for mixed crews was 15.54 minutes compared with 16.92 minutes for all-APS crews. This difference is statistically significant (p=0.002). All-APS crews performed a slightly higher number of APS procedures (0.90/time critical case versus 0.76/time critical case; p=0.001). There was no significant difference in procedure failure rates.

Conclusion: Mixed crews demonstrated shorter scene times than all-APS crews, although this is unlikely to be clinically significant. The concern that mixed crews would have longer scene time was not substantiated and should not be considered as a barrier to the development of mixed crew staffing models.

Out-of-hospital spinal immobilization: its effect on neurologic injury

Hauswald M, Ong G, Tandberg D, Omar Z

Department of Emergency Medicine, University of New Mexico, School of Medicine, Albuquerque 87131-5246, USA. mhauswald@salud.unm.edu

OBJECTIVE: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries.

METHODS: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables.

RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.

Acad Emerg Med. 1998 Mar;5(3):203-4

Acad Emerg Med 1998 Mar;5(3):214-9Related Articles

Intubation by ALS Medics doesn't help children

But the study notes that among children who were intubated, scene time was increased and fatal complications were frequent. The study recommends that the focus be on training EMS providers to perform effective bag-valve-mask ventilation, coupled with firstline medications and expeditious transport.

In an accompanying editorial article, Dr. Peter Glaeser of the University of Alabama at Birmingham calls into question the type of training with BVM and intubation. There are many factors and training may have been inadequate, and adds that it would be premature to conclude that out-of-hospital intubation for children should not be performed in any situation. Glaeser agrees that the onus of responsibility is on the medical directors of emergency medical services systems that continue performing intubation and other invasive skills out of hospital to demonstrate to the public that each of these procedures is reasonably safe and effective.

SOURCE: The Journal of the American Medical Association 2000;283:783-790, 797-798.

How Valuable is the Use of Lights and Siren?

Following is a citation of a study to determine if the use of lights and siren results in faster transport times from the scene to the Emergency Department.

Methodology: Ambulance transport times from the scene to the ED were compared using an experimental group that transported without lights and siren, and a control group using lights and siren. Routes and time length were recorded by an observer during actual patient transport. A simulated transport was then performed during the same day and time without the use of lights and siren, and obeying all traffic regulations. The driver re-corded the length of the transport.

Results: The ambulances using lights and siren averaged 43.5 seconds faster than those that did not use lights and siren. The range of transport times with ambulances using lights and siren was 104 to 927 seconds with a mean of 362 seconds. The range of transport times of ambulances not using lights and siren was 129 to 881 seconds, with a mean of 406 seconds.

All ambulances in the lights and siren group used flashing red warning lights and most used sirens intermittently. Forty-one of the lights and siren transports, and the 41 corresponding simulated transports, took place on a weekday. All were conducted on dry roads with full visibility.

Conclusions: Except in extreme clinical circumstances, a mean savings of 43.5 seconds does not warrant the use of lights and siren during ambulance transport.

Citation: Hunt RC, Brown LH, Cabinum ES et al (Pitt County Memorial Hosp, Greenville, NC, USA) Is ambulance transport time with lights and siren faster than that without? Annals of Emergency Medicine 1995; 25:507-511 (11 ref). from Emergindex® Clinical Abstracts

Automated external versus blind manual defibrillation by untrained lay rescuers.

Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.

Resuscitation, 33(3):219-21 1997 Jan

INTRODUCTION: sudden cardiac death is an important cause of mortality in the United States today. A major determinant of survival from sudden cardiac death is rapid defibrillation. Communities with high rates of bystander cardiopulmonary resuscitation (CPR) and early defibrillation enjoy the highest survival rates from out-of-hospital cardiac arrest. First responders and emergency medical technicians (EMTs) have been trained to use external defibrillators (AEDs). The period of instruction for successful use of the AED remains to be determined. It was the purpose of this study to compare AED versus blind manual defibrillation (BMD) by untrained lay rescuers using a simple instruction sheet and following a 20-min training period.

METHODS: 50 employed volunteers were confronted with a stimulated cardiac arrest and asked to attempt defibrillation using either AED or BMD by following a written instruction sheet. Success was defined as delivery of three countershocks during the simulated resuscitation. Time to first and third shocks were recorded.

RESULTS: 24 of 25 volunteers (96%) were successful in operating the AED compared to none in the BMD group. Time to delivery of first shock averaged 119.5 +/- 45.0 s and time to third shock averaged 158.7 +/- 46.3 s. A 95% confidence interval for time to first shock for untrained lay rescuers was 100.5-138.4 s.

CONCLUSIONS: untrained lay rescuers demonstrated a very high success rate using the AED during simulated cardiac arrest. Success with BMD by untrained rescuers is poor. This study suggests that prehospital personnel can be successfully trained in the use of AED in a substantially shorter period of time than in current practice. Strategic placement of AEDs like fire hoses and pool-side life preservers could result in improved survival from sudden cardiac death.

MESH Headings

Ambulatory Care ; Cardiopulmonary Resuscitation *MT ; Comparative Study ; Confidence Intervals ; Electric Countershock *MT ; Heart Arrest MO/*TH ; Human ; Models, Theoretical ; Survival Rate ; Texas

Publication Type

CLINICAL TRIAL; JOURNAL ARTICLE

ISSN

0300-9572

Country of Publication

IRELAND

Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest.

Author Davis EA; Mosesso VN Jr

Department of Emergency Medicine, University of Rochester, NY 14642, USA.

Prehosp Emerg Care, 2(2):101-7 1998 Apr-Jun

Abstract

OBJECTIVE: Rates of resuscitation from cardiac arrest are directly tied to time to defibrillation. To maximize results, the first arriving care provider should be equipped and trained to defibrillate. This would include police in those systems where they serve this function; to date, no training program has been examined for effectiveness in this group. The purpose of this study was to evaluate a training program designed to train police first responders in the use of an automated external defibrillator (AED).

METHODS: One hundred seventy police officers previously trained to the level of first responders underwent a four-hour course to teach incorporation of the AED in their practice. The evaluation of police performance was assessed by written tests prior to, immediately after, and six months post initial training. Actual field use was evaluated by using separate data collection forms filled out at the time of the resuscitation by both police and EMS providers. Each trip sheet was also reviewed. Cassette tapes from the AED were reviewed for continuous ECG tracings and audio recordings to validate and confirm the previous data.

RESULTS: One hundred twenty-eight police cases were reviewed. The officers performed with few errors in AED operation, with the only problem areas being incorrect airway management and delay in performance of CPR to use the AED to reanalyze a nonshockable rhythm. These results were compared with those of the only two other studies examining the performance of first responders, which were EMTs and firefighters. The police results compared favorably with, and in some instances exceeded, those results.

CONCLUSION: Police first responders trained in the use of AEDs performed at a level equivalent or superior to that in other reported studies. Future training strategies should stress proper integration of airway and CPR skills.

Language

Eng

MESH Headings

Automation ; Clinical Competence * ; Documentation ; Electric Countershock IS/*ST ; Emergency Treatment *IS ; Heart Arrest DI/*TH ; Human ; Pennsylvania ; Police *ED ; Program Evaluation

Publication Type

JOURNAL ARTICLE

ISSN

1090-3127

Country of Publication

UNITED STATES

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.

Author Sweeney TA; Runge JW; Gibbs MA; Raymond JM; Schafermeyer RW; Norton HJ; Boyle-Whitesel MJ

Department of Emergency Medicine, Medical Center of Delaware, Wilmington, USA.

Ann Emerg Med, 31(2):234-40 1998 Feb

Abstract

OBJECTIVE: The use of automatic external defibrillators (AEDs) by EMS initial responders is widely advocated. Evidence supporting the use of AEDs is based largely on the experience of one metropolitan area, with effect on survival in many systems not yet proved. We conducted this study to determine whether the addition of AEDs to an EMS system with a response time of 4 minutes for first-responder emergency medical technicians (FREMTs) and 10 minutes for paramedics would affect survival from cardiac arrest.

METHODS: This prospective, controlled, crossover study (AED versus no AED) of consecutive cardiac arrests managed by 24 FREMT fire companies took place from 1992 to 1995 in Charlotte, North Carolina, a city of 455,000. Patients were stratified using the Utstein criteria. The primary endpoint was survival to hospital discharge among patients with bystander-witnessed arrests of cardiac origin.

RESULTS: Of the 627 patients, 243 were bystander-witnessed arrests of cardiac origin. Survival to hospital discharge was accomplished in 5 of 110 patients (4.6%; 95% confidence interval [CI] 0.6% to 8.4%) with AED compared with 7 of 133 (5.3%, 95% CI 1.5% to 9.1%) without AED (P = .8). Both groups were comparable with regard to age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and whether or not ventricular fibrillation (VF) was the initial rhythm. For arrests of any cause, witnessed by bystanders or EMS personnel, with an initial rhythm of VF or ventricular tachycardia (VT), 5 of 77 (6.5%, 95% CI 1.0% to 12.0%) with AED survived compared with 8 of 105 patients (7.6%, 95% CI 2.5% to 12.7%) without AED (P = .8). Statistically significant differences were noted in race and EMS response times between the two groups, which did not affect survival.

CONCLUSION: Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.

Language

Eng

Unique Identifier

98132772

MESH Headings

Aged ; Cardiopulmonary Resuscitation ; Comparative Study ; Cross-Over Studies ; Death, Sudden, Cardiac *PC ; Electric Countershock * ; Emergency Medical Service Communication Systems ; Emergency Medical Services *SN ; Female ; Heart Arrest MO/*TH ; Human ; Male ; Middle Age ; Outcome Assessment (Health Care) ; Prospective Studies ; Suburban Health Services ; Support, Non-U.S. Gov't ; Survival Analysis ; Urban Health Services

Publication Type

CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL ARTICLE

ISSN

0196-0644

Country of Publication

UNITED STATES

Prehosp Emerg Care 1998 Oct-Dec;2(4):274-9

The impact of paramedics on out-of-hospital cardiac arrests in a rural community.

City of Ketchikan Fire Department, Alaska, USA.

OBJECTIVE: To determine whether paramedics influence the outcome of cardiac arrest patients in a rural area.

METHODS: Retrospective analysis of cardiorespiratory arrest patients in rural southeast Alaska from 1987 to 1996.

RESULTS: Paramedics treated 37 patients and advanced life support emergency medical technicians (EMT-IIIs) treated 34 patients. Demographics/CPR variables of the two groups were similar. Return of spontaneous circulation (ROSC) was 46% (17/37) for the paramedic-treated patients and 18% (6/34) for the EMT-III-treated patients (p = 0.01). Intensive care unit (ICU) admission was 38% (14/37) for the paramedic-treated patients and 15% (5/34) for the EMT-III-treated patients (p < 0.03). Discharge from the hospital neurologically intact was 20% (7/35) for the paramedic-treated patients and 9% (3/34) for the EMT-III-treated patients (p = NS). Two patients in the paramedic-treated group had ROSC and survived in the local hospital ICU for several days before being transferred to a tertiary care hospital in another state and were lost to follow-up for the discharge-from-hospital-neurologically-intact category but were included in the ROSC and ICU admission analysis.

CONCLUSION: In this rural setting, a paramedic on the scene significantly improved the ROSC (paramedics = 46% vs 18% for EMT-III, p = 0.01) and survival to ICU admission (38% vs 15%, p = 0.03). The presence of a paramedic on the scene increased survival to hospital discharge neurologically intact (20% vs 9%), although this was not statistically significant.