Can Medical Decision-making at the Scene by EMS Staff Reduce the Number of Unnecessary Ambulance Transportations, but Still Be Safe?

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Objectives: The aim of this study was to evaluate the procedures adopted by the staff of the Shiraz Emergency Medical Services (EMS) and the outcome of the patients discharged from the scene over a one-year period.  

Background: Unnecessary use of ambulances results in the overloading of EMS and the over-crowding of emergency departments. Medical assessment at the scene by EMS staff may reduce these issues. In an earlier study in Shiraz, 36% of the patients were left at home/discharged directly from the scene with or without treatment by EMS staff after consulting a physician at the dispatch center. However, there has been no evaluation of this system with regard to mortality and morbidity.  

Materials and Methods: Retrospective data on all missions performed by the Shiraz EMS (2012-2013) were reviewed. All the patients discharged from the scene by the EMS staff on the 5th, 15th, and 25th days of each month were included. A questionnaire with nine questions was designed, and available patients/relatives were interviewed prospectively (2014; follow-up period 4-12 months).  

Results: Out of 3019 cases contacted, 994 (almost 33%) replied. There were 26%-93% reductions in the complaints in all disease categories. A group of the patients left the scene at their own will. Of those who were discharged by the EMS staff at the scene, over 60% were without any complaints. Twelve out of 253 patients died after they were sent home by the EMS staff.   Conclusions: Patients may be discharged at the scene by EMS staff and after consulting a physician. However, there is a need for a solid protocol to ensure total patient safety. This calls for a prospective study. 

Challenging Operations: An Ethical Framework to Assist Humanitarian Aid Workers in their Decision-making Processes

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Introduction: This paper aims to raise awareness regarding ethical issues in the context of humanitarian action, and to offer a framework for systematically and effectively addressing such issues.

Methods: Several cases highlight ethical issues that humanitarian aid workers are confronted with at different levels over the course of their deployments. The first case discusses a situation at a macro-level concerning decisions being made at the headquarters of a humanitarian organization. The second case looks at meso-level issues that need to be solved at a country or regional level. The third case proposes an ethical dilemma at the micro-level of the individual patient-provider relationship.

Discussion: These real-life cases have been selected to illustrate the ethical dimension of conflicts within the context of humanitarian action that might remain unrecognized in everyday practice. In addition, we propose an ethical framework to assist humanitarian aid workers in their decision-making process. The framework draws on the principles and values that guide humanitarian action and public health ethics more generally. Beyond identifying substantive core values, the framework also includes a ten-step process modelled on tools used in the clinical setting that promotes a transparent and clear decision-making process and improves the monitoring and evaluation of aid interventions. Finally, we recommend organizational measures to implement the framework effectively.

Conclusion: This paper uses a combination of public health/clinical ethics concepts and practices and applies them to the decision-making challenges encountered in relief operations in the humanitarian aid context.