Boerhaave syndrome is a spontaneous rupture of the esophagus. It results from a sudden increase in esophageal pressure combined with negative intrathoracic pressure as seen with severe straining or vomiting. Esophageal perforation is extremely rare with an incidence of approximately 3.1 per 1,000,000 per year with a mortality rate estimated to be 20-50%. The rare occurrence and fatal nature of an esophageal perforation makes this syndrome a difficult yet important diagnosis to consider in the clinical setting. This case presents a previously healthy 47-year-old gentleman who presented to a local emergency department with syncope, vomiting, and chest pain sequentially. He reported a 24-hour history of dark stools followed by syncope, and when he regained consciousness he had three bouts of retching and expulsion of coffee-ground vomitus. Shortly after emesis, the patient developed severe and continuous pain located in his central chest that radiated to his back. Upon arrival to the hospital he was tachycardic. Blood tests revealed metabolic acidosis, increased white blood cell count, elevated lactate, and significant anemia. The patient’s hemoglobin was 7.7 gm/dL, a significant drop from the patient’s baseline level of 14. The patient received 1 unit of packed red blood cells and was sent for imaging studies. Chest X-ray and CT imaging revealed free air in the mediastinum, and a subsequent Gastrografin esophagogram study revealed a lower esophageal perforation proximal to gastroesophageal junction. The patient was rushed to the operating room for emergency surgery. An esophagogastroduodenoscopy showed no active bleeds and confirmed a distal mucosal defect suggestive of perforation. The surgery team then performed a left thoracotomy with intercostal muscle harvest and esophageal repair, with the patient needing an additional 4 units of packed red blood cells during surgery. He tolerated the surgery well and received appropriate post-op care in the ICU. A repeat Gastrografin and barium swallow esophagogram revealed no evidence of leak, strictures, or complications from the operation. A follow up CT image of the chest, abdomen, and pelvis was performed one month after hospital discharge, and results showed complete resolution of mediastinal air without evidence of esophageal leak. This case demonstrates how a spontaneous esophageal perforation can occur in previously healthy, middle aged patients with no significant GI history or identifiable risk factors. Given this information, clinicians should consider Boerhaave Syndrome when a patient of any age presents with chest pain after an episode of emesis.

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Sepsis is a complicated disorder in which an infection has reached the bloodstream and caused a cascade of events that in time will lead to death. Interventions aimed at identifying sepsis early in its progression are imperative to stopping the process. The purpose of this study is to examine the current state of the literature regarding sepsis screening tools utilized by emergency medical services. A literature review exploring the various tools in place was conducted to see their value in predicting sepsis and secondary what the initiation of a sepsis alert has on the patients’ outcome. Results found included that sepsis screening tools when in place decrease time to identification, decrease time to antibiotics, increase amount of fluid administration, and overall reduce hospital stay and mortality rate. With these findings educational training for EMS providers and the introduction of generalized protocols are of the upmost importance. Further research is needed to be done to create a consistent tool to be used by all EMS agencies that has a validated predictive value of sepsis.

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<p>Inappropriate ambulance use can be defined broadly as the use of emergency medical services (EMS) transport for non-urgent medical conditions, or when the patient does not use alternate transportation available. It drains health system resources, contributes to low morale among paramedics, and can delay care for patients who may be appropriately treated in alternative settings. An increasing number of studies indicate <em>that</em> inappropriate EMS use occurs, but few studies investigate how perspectives of inappropriate use are constructed. This study explores the construct of appropriateness in the context of ambulance use, and examines the implications of varying perspectives on ambulance billing policies.</p> <p>We present a grounded theory on the construct of appropriate ambulance use from interviews with paramedics in Ontario, national media reports and online reader commentary. Findings show that the role of paramedics varies across regions, and includes various types of care (e.g., emergency response, primary care and preventative care), and transportation (e.g., to the emergency department or urgent care clinics). In turn, constructs of appropriateness vary. In ambiguous cases, paramedics use their perception of the patients’ ability or attempts to cope with the medical situation to evaluate the appropriateness of ambulance use. Unexpectedly, the most frustrating cases of inappropriate ambulance use tend to be initiated by organizations, such as long-term care facilities, rather than members of the general public. These findings raise questions about the potential for ambulance user fees conditional on ‘appropriateness’ to improve either the effectiveness or the efficiency of ambulance services.</p> / Doctor of Philosophy (PhD)

Registered nurse (RN) insufficiency is both a major contributor to and effect of emergency department overcrowding (EDOC) in the United States and is implicated in increased patient mortality, ED wait times, and general congestion of the healthcare system. Licensed paramedics represent a viable solution to this crisis given their extensive training in emergency care by serving as RN adjuncts and alternatives in the ED setting. Paramedics utilize high-level clinical judgment and patient assessment skills to form detailed clinical impressions and employ a wide range of therapies to initiate treatment. Although they less frequently possess a college degree than their RN counterparts, paramedics complete a comparable study of medical science principles, patient assessment, and pathophysiology, and devote significantly more time to critical care and emergency medicine than RNs. Implementation of paramedics in U.S. EDs in the 1980s and 1990s highlighted their manual and technical skill prowess as well as their ability to rapidly assess emergency situations, including their unexpectedly widespread use in pediatric EDs. Modern implementation includes expansion of the psychomotor skills available to ED-based paramedics, with emphasis on medication administration and emergency procedures, but there is a significant lack of research into paramedic assessment and triage skills in the ED. Barriers to further implementation of ED paramedics include resistance from nursing advocacy organizations, regulatory and legal challenges, and public opinion and attitudes of nurses and paramedics. Nursing advocacy groups have historically opposed paramedic integration, fearing job encroachment and increased autonomy for non-nursing healthcare professionals. Regulatory challenges involve certification vs licensure discrepancies, limitations on paramedic scope of practice, and the wide-reaching effects of state Nurse Practice Acts. Societal resistance, cultural factors, and attitudes within the nursing and paramedic communities also impede further ED paramedic implementation. Practice recommendations are proposed, including the development of standardized ED orientation programs for paramedics, and redefining the minimum education for paramedics at the associate degree level. Legislative recommendations involve eliminating statutory restrictions on paramedic practice, reevaluating language in state Nurse Practice Acts, and clarifying the legal relationship between RNs and ED paramedics. The limitations of this literature-based thesis include a lack of large-scale studies, regional variability, and the absence of empirical examination of paramedic integration in reducing ED overcrowding. Future suggestions for study include randomized controlled trials comparing ED patient outcomes between RNs and paramedics, interrater reliability studies on assessment and triage skills, and comparisons of scope of practice and education between paramedics in different countries.