Unfortunately, limiting space may also limit the room for positive evaluation and strings of praising adjectives.However, while implicit bias exists, employing limits in response format may rein in the manifestation of implicit bias by focusing the writer.This was a single center study; only SLOE narratives from applicants who applied to interview at a single, academic EM residency program were included in analysis, and applicants from non-LCME schools were excluded, limiting generalizability. The man to woman applicant ratio in this study reflects the national trend for the 2017 match, which may contribute to generalizability.ERAS does not allow an individual program to access SLOEs for applicants who have not selected that program; therefore, a full national sample of all applicants in a single year to ERAS was not feasible. Our analysis used the LIWC linguistic software and focused on individual words. Other approaches, such as qualitative content analysis or focusing on phrases or searching for specific words as was done by Friedman and colleagues in the study discussed above may have yielded different findings. Additionally, the LIWC contains pre-established word lists. While these lists have been used in medical literature,it is possible that there may be a set of words for EM that is more applicable. Our analysis used word frequency as a measurement of biased language and did not evaluate context of the words in the letters, limiting the study. Words in different contexts can have different meaning. For instance,horticulture products the word “aggressive” can have both a positive or negative connotation based on context when describing and applicant as “aggressive in picking up patients” vs “aggressive with consultants.”
A qualitative analysis of the SLOEs would better delineate the context of word phrases and provide a more in-depth analysis. Although it is a limitation that we did not evaluate word context, word frequency software applied to a large sample gives generalizability that a small qualitative analysis may not be able to achieve. In these rare instances of context misinterpretation for positive and negative emotion categories , this may be of little overall consequence as there is such a large margin between median positive vs negative words within these word categories . Additionally, the subtle differences between word phrases such as “we strongly recommend this student” vs “we will be recruiting this student” would not be picked up by the software. This was an exploratory study and as such was not powered to a specific outcome; however, we estimated that with our sample size of 822 that we would have 80% power to detect a difference of 0.2 mean words within a single word category with a 5% type I error . Additionally, it is possible that the sample was under powered to detect small wording differences among the 16 word categories, which could represent a type II error. We did not replicate the findings of our previous study with regard to differences in the same word categories, further adding to this concern. However, we are equally interested in the lack of a difference as we are in detecting differences. Although negative findings are often highlighted less than positive ones, this analysis did not find a difference in the majority of word categories .
Finally, as the majority of letters do not denote letter-writer gender and most were composed by a group of authors, this group composition did not allow for any evaluation of the relationships between author gender and applicant gender with respect to language used in the SLOE.In the 1970s, priority emergency medical services dispatch systems were introduced to help triage 911 calls and resources. Since then, multiple versions of dispatch triage, including criteria-based dispatch, medical priority dispatch systems, and locally developed protocols have been used. Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Division of Emergency Medical Services, Los Angeles, California Los Angeles Fire Department, Emergency Medical Services Bureau, Los Angeles, California * † However, most dispatch systems have a high rate of overtriage, leading to increased costs, increased utilization of limited resources, and increased use of lights and sirens, all without clear evidence of outcomes that suggest improved patient care.Many studies suggest that priority dispatch systems lead to overtriage of Advanced Life Support units with <1% of low-acuity calls requiring ALS resources.For this reason, multiple large cities with accelerating EMS call volumes are re-evaluating their current dispatch systems. Multiple studies have attempted to identify low-acuity chief complaints and triage criteria at the 911-dispatch level to better optimize allocation of resources. Although abdominal pain is one of the most common reasons 911 is activated, few studies have specifically examined dispatch protocols for abdominal pain. The few studies that have been published suggest over triage and overutilization of ALS resources for abdominal pain with a range from 10-51%.Other retrospective reviews found that 84-98% of abdominal pain calls are low acuity and that less than 6-8% were considered true emergencies.
Of note, most ALS care was pulse oximetry and/or an intravenous placement, and when the analysis was restricted to IV fluid bolus, medication, intubation or defibrillation, the majority received ALS <10% of time.Although more than 85% of 911 incidents for abdominal pain require only Basic Life Support transport to the emergency department ,many dispatch systems continue to send ALS resources, sometimes in addition to the closest first responder units. In 2015, the Los Angeles Fire Department implemented an internally developed tiered dispatch system . Under LA-TDS, patients reporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. If no BLS ambulance was available within three miles, then a closer paramedic ambulance was dispatched, and if no ambulance was available within three miles, a BLS fire company responded emergency along with the closest ambulance non-emergency. The purpose of this study was to evaluate the safety of this dispatch algorithm by determining the prevalence of 911 patients with abdominal pain and a documented time-sensitive event.The LAFD is a tiered, fire-based EMS provider system, and it is the sole provider of 911-EMS response for the City of Los Angeles. The department covers 480 square miles and serves a population of 4.2 million people. All 911-call takers are sworn members of the LAFD and are either firefighter/ paramedics or firefighter/emergency medicine technicians who are certified as emergency medical dispatchers. A resource is dispatched to all calls, and there is mandatory offer of ambulance transport to an ED. LAFD-TDS is a homegrown dispatch system that was implemented in 2015 with the goal of improving call processing times, cardiac arrest recognition, resource availability and response times. Under LAFD-TDS, patients reporting a chief complaint of abdominal pain receive the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. While the dispatch protocol calls for a BLS ambulance, the dispatch protocol dictates that an ALS ambulance responds if no BLS ambulances are available within three miles. Of note, in this system, only ALS providers can perform prehospital electrocardiograms . However, given that ALS providers may be dispatched to these calls, ECGs are occasionally performed on patients with non-traumatic abdominal pain who met our study inclusion criteria.This was a retrospective review of electronic health records for 911 incidents dispatched as non-traumatic abdominal pain from May 2015–May 2018. Cases were included if the patient’s chief complaint was abdominal pain, the patient was the caller or was in close proximity to the caller ,plant grow trays the patient was over age 15, and the patient was awake and breathing normally. All calls that met this inclusion criteria regardless of resource dispatched or transport to an ED were included in the study. The primary outcome was the prevalence of documented, time-sensitive prehospital events that require emergent lifesaving interventions, defined as cardiopulmonary resuscitation , defibrillation, or airway management . Secondary outcomes were incidents that could potentially benefit from ALS resources and included the presence of hypotension or a prehospital 12-lead ECG that was read as ST-elevated myocardial infarction or wide complex arrhythmia by computer software. ECGs that were marked as STEMI or wide complex arrhythmia were reviewed and interpreted by the authors . Descriptive statistics are presented, including frequencies. We excluded all incidents that were the result of trauma.
Audios from the 911 calls for cases involving CPR, defibrillation, or airway management were reviewed. We used qualitative analysis to identify any themes or key words in the calls. Additionally, dispatch protocol adherence was evaluated. This study was approved by the institutional review board of the University of Southern California .Abdominal pain is a common medical reason for 911 activation. In an environment with limited resources and increasing 911-call volumes, minimizing overtriage is essential to ensure ALS resources are available for true, time-critical emergencies. By introducing a tiered-dispatch system that dispatches a BLS ambulance alone for non-traumatic abdominal pain in patients who are awake and breathing normally, there is a potential opportunity to free up more ALS and first-responder resources to respond to true, time-critical calls. Time-sensitive events were identified in only 0.021% of all cases meeting inclusion criteria, which is considerably lower than LAFD’s overall rate of 0.82% for time-sensitive events for all EMS 911 calls during the study period. The need for airway management or CPR was extraordinarily rare among the 33,000 abdominal pain dispatches under study. Furthermore, in two of the seven cases, if dispatch protocol had been followed correctly, ALS resources would have been deployed, decreasing the frequency from 0.021% to 0.015%, ie, 1.5 in 10,000 patient dispatches. This underscores the importance of a robust, dispatch quality improvement program. Close monitoring, feedback, and education are necessary to ensure that the system is being properly used to protect the public and allow for effective and efficient dispatch protocols. Hypotension was the most common outcome of interest that was documented. However, it is difficult to infer the clinical significance of these numbers and whether a closer first responder or an ALS response with IV fluids would have been of benefit. ECGs that met STEMI criteria were also very uncommon events in this cohort. None of the patients with ECGs that met STEMI criteria were hypotensive upon EMS arrival nor did they require CPR, airway management, or defibrillation prior to ED arrival. Furthermore, 50% of them were deemed to be false positives by the software algorithm. Finally, there is an association between age and time sensitive outcomes. Patients who had time-sensitive events tended to be older and female . Additionally, patients with ECGs that met STEMI criteria also tended to be older . While patients over the age of 65 accounted for 21.9% of all included calls, they made up 85.7% of time-sensitive events. Prior research suggests the addition of paramedic endotracheal intubation in pediatric patients does not McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan Houston Fire Department, Houston, Texas improve survival or neurologic outcomes in children.Median success rates for prehospital ETI in the United States are lower than those for extraglottic airway placement.Currently, the national emergency medical services educational standards for paramedics do not define intubation training requirements for paramedics.Also, paramedics have few requirements during training to adequately practice the skill of intubation,and few ongoing opportunities to maintain proficiency.Neonatal resuscitations that use EGAs have demonstrated safety, high placement success, and improved resuscitation rates when compared to bag-valve mask ventilation .Limited data exists across the entire pediatric age spectrum on the use of EGAs, especially in EMS. A National Association of EMS Physicians position statement recommends that EMS have at least one blindly inserted nonsurgical airway available.8 Likewise, the American Academy of Pediatrics Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatrics Committee have recommended the inclusion of EGAs with supplies for difficult airway conditions in the emergency department.In 2014 the National Association of State EMS Officials published its Model Clinical EMS Guidelines, which included recommendations from an evidence-based guideline for pediatric airway management that was implemented as part of a separate project in several New England states and the City of Houston Fire Department .