William Fales

(2020). Ethical Allocation of Remdesivir. The American Journal of Bioethics: Vol. 20, No. 7, pp. 84-86.

Background: Pediatric drug dosing errors occur at a high rate in the prehospital environment. Objective: To describe paramedic training and practice regarding pediatric drug administration, exposure to pediatric drug dose errors and safety culture among paramedics and EMS agencies in a national sample. Methods: An electronic questionnaire was sent to a random sample of 10,530 nationally certified paramedics. Descriptive statistics were calculated. Results: There were 1,043 (9.9%) responses and 1,014 paramedics met inclusion criteria. Nearly half (43.0%) were familiar with a case where EMS personnel delivered an incorrect pediatric drug dose. Over half (58.5%) believed their initial paramedic program did not include enough pediatric training. Two-thirds (66.0%) administered a pediatric drug dose within the past year. When estimating the weight of a pediatric patient, 54.2% used a length-based tape, while 35.8% asked the parent or guardian, and 2.5% relied on a smart phone application. Only 19.8% said their agency had an anonymous error-reporting system and 50.7% believed they could report an error without fear of disciplinary action. For solutions, 89.0% believed an EMS-specific Broselow-Luten Tape would be helpful, followed by drug dosing cards in milliliters (83.0%) and changing content of standardized pediatric courses to be more relevant (77.7%). Conclusion: This national survey demonstrated a significant number of paramedics are aware of a pediatric dosing error, safety systems specific to pediatric patients are lacking, and that paramedics view pediatric drug cards and eliminating drug calculations as helpful. Pediatric drug-dosing safety in the prehospital environment can be improved.

Objective:An effective response to a pandemic influenza assumes an adequate supply of a variety of skilled healthcare workers (HCWs). But what is known of HCWs’ willingness to report to work?Method:We identified 206 relevant studies from 9 healthcare databases. Of 28 heterogeneous studies that met inclusion criteria, 18 used common methods for calculating percentages of HCWs willing to report to work. Their findings were evaluated in greater depth.Results:In 28 studies that summarized willingness to report to work of 31,633 workers, the percentage of HCWs willing to report to work varied between 23.10% and 93.10%. Scale type and dichotomization of self-report scales led to significantly different results. In 4 studies where 2097 workers responded to a survey during an actual event (2009 H1N1 pandemic influenza) percentage willing to report to work varied from 23.1% to 90.1%. In 6 studies with hypothetical scenarios of avian influenza 50%–82.50% of HCWs were willing to report to work.Conclusion:The studies we reviewed have methodological problems and inconsistencies in findings, even within relatively homogenous study subgroups. We caution emergency planners from relying on findings from any single study that estimates HCWs’ mean willingness to report to work in a pandemic influenza outbreak.

Introduction. Early CPR and use of automated external defibrillators (AEDs) have been shown to improve cardiac arrest (CA) outcomes. Placement of AEDs on golf courses has been advocated for more than a decade, with many trade golf publications calling for their use. Objective. To describe the incidence and treatment of CAs at Michigan golf courses and assess the response readiness of their staff. Methods. We performed a retrospective study of CA on Michigan golf courses from 2010 to 2012. Cases were identified from the Michigan EMS Information (MI-EMSIS) database. Cases with “golf” or “country club” were manually reviewed and location type was confirmed using Google Maps. We conducted a structured telephone survey capturing demographics, course preparedness, including CPR training and AED placement, and a description of events, including whether CPR was performed and if an AED was used. Our primary area of interest was the process of care. We also recorded return of spontaneous circulation (ROSC) as an outcome measure. EMS Utstein data were collected from MI-EMSIS. Descriptive data are presented. Results. During the study period, there were 14,666 CAs, of which 40 (0.18%) occurred on 39 golf courses (1 arrest/64 courses/year). Of these, 38 occurred between May and October, yielding a rate of 1 arrest/33.5 courses/golf season. Almost all (96.2%) patients were male, mean age 66.3 (range 45–85), 68% had VT/VF, and 7 arrested after EMS arrival. Mean interval from 9-1-1 call to EMS arrival at the patient was 9:45 minutes (range 3–20). Of all cases, 24 (72.3%) patients received CPR with 2 patients having CPR performed by course staff. Although AEDs were available at 9 (22.5%) courses, they were only placed on 2 patients prior to EMS arrival. Sustained ROSC was obtained in 12 (30.0%) patients. Only 7, (17.9%) courses required CPR/AED training of staff. Conclusion. When seasonally adjusted, the rate of cardiac arrest on Michigan golf courses is similar to that of other public locations. AED use was rare even when available. Preparedness for and response during a CA is suboptimal. Despite more than a decade of advocacy, response to golf course cardiac arrest is still not up to par.

Introduction Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. Methods Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects’ explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. Results One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. Conclusions We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors.

Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery.

The objective of the study was to examine available evidence on healthcare providers’ willingness to report to work during a pandemic influenza and...

ACADEMIC EMERGENCY MEDICINE 2012; 19:37–47 © 2012 by the Society for Academic Emergency Medicine Objectives:  Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug‐dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency.Methods:  Two‐person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods.Results:  Forty‐five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners.Conclusions:  Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error‐producing conditions in EMS pediatric care.

Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients. To characterize medication dosing errors in children treated by EMS. We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone. There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%. Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.

The goals of this study were to evaluate whether the increased use of skate shoes may lead to an increase in injuries for children and adolescents aged 5 to 14 years in the United States and to describe the types of injuries reported by emergency departments as a result of skate shoe use. Retrospective analysis of the National Electronic Injury Surveillance System database from January 1, 2002 to December 31, 2006 for injuries resulting from footwear in children and adolescents aged 5 to 14 years. Injuries resulting from skate shoe use were identified by manual review of the data. For the 5-year period, an estimated 3525 patients between 5 and 14 years of age were treated in United States emergency departments for injuries resulting from skate shoe use. The percentage of injuries resulting from skate shoes of total footwear-related injuries varied by year, however, with 1.0%, 1.0%, 0.8%, and 1.9% occurring in 2002 to 2005, respectively, and 11.8% occurring in 2006. This substantial increase in 2006 accounts for 73.6% of skate shoe-related injuries and is statistically significant (chi, P = <0.0001). This rising trend in 2006 paralleled national skate shoe sales, with a correlation coefficient of 0.9982.Most of the injured children and adolescents were white, and there was a slight, nonsignificant predominance of boys. Most injuries in all 5-year-olds were fractures (46.7%), followed by contusions (17.9%) and sprains (17.2%). The most frequent site of fracture was the forearm (38.4%), followed by the wrist (35.1%) and the leg (14.9%). Other injuries included lacerations (7.3%), concussions (6.6%), internal organ injuries (0.9%), hematomas (0.2%), dislocations (0.2%), and injuries not otherwise specified (3.1%). Based on national estimates, 104 (0.01%) patients required admission to the hospital. No injuries recorded in the National Electronic Injury Surveillance System database resulted in death. As the first study analyzing injury rates as a result of skate shoe use in the United States, this study demonstrated a recent increase in injuries to children and adolescents using skate shoes, which paralleled the products' sales increase. The types of injuries are primarily a wide range of non-life threatening bone and soft tissue injuries.