Michael G Millin

Johns Hopkins University, Baltimore, MD, United States

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Publications (23)62.13 Total impact

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    ABSTRACT: In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons' Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.
    The journal of trauma and acute care surgery. 09/2013; 75(3):459-467.
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    ABSTRACT: Abstract This position statement with accompanying resource document is the result of a collaborative effort of a writing group comprised of members of the Air Medical Physician Association (AMPA), the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the American Academy of Emergency Medicine (AAEM). This document has been jointly approved by the boards of all four organizations. Patients benefit from the appropriate utilization of helicopter emergency medical services (HEMS). EMS and regional health care systems must have and follow guidelines for HEMS utilization to facilitate proper patient selection and ensure clinical benefit. Clinical benefit can be provided by Meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions Providing necessary specialized medical expertise or equipment to patients before and/or during transport Providing transport to patients inaccessible by other means of transport The decision to use HEMS is a medical decision, separate from the aviation determination whether a transport can be completed safely. Physicians with specialized training and experience in EMS and air medical transport must be integral to HEMS utilization decisions, including guideline development and quality improvement activities. Safety management systems must be developed, adopted, and adhered to by air medical operators when making decisions to accept and continue every HEMS transport. HEMS must be fully integrated within the local, regional, and state emergency health care systems. HEMS programs cannot operate independently of the surrounding health care environment. The EMS and health care systems must be involved in the determination of the number of HEMS assets necessary to provide appropriate coverage for their region. Excessive resources may lead to competitive practices that can affect utilization and negatively impact safety. Inadequate resources will delay receipt of definitive care. National guidelines for appropriate utilization of HEMS must be developed. These guidelines should be national in scope yet allow local, regional, and state implementation. A National HEMS Agenda for the Future should be developed to address HEMS utilization and availability and to identify and support a research strategy for ongoing, evidence-based refinement of utilization guidelines. Key words: appropriateness; helicopter; HEMS; safety; utilization.
    Prehospital Emergency Care 07/2013; · 1.86 Impact Factor
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    ABSTRACT: Introduction Much attention has been given to the strategic placement of automated external defibrillators (AEDs). The purpose of this study was to examine the correlation of strategically placed AEDs and the actual location of cardiac arrests. METHODS: A retrospective review of data maintained by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), specifically, the Maryland Cardiac Arrest Database and the Maryland AED Registry, was conducted. Location types for AEDs were compared with the locations of out-of-hospital cardiac arrests in Howard County, Maryland. The respective locations were compared using scatter diagrams and r2 statistics. RESULTS: The r2 statistics for AED location compared with witnessed cardiac arrest and total cardiac arrests were 0.054 and 0.051 respectively, indicating a weak relationship between the two variables in each case. No AEDs were registered in the three most frequently occurring locations for cardiac arrests (private homes, skilled nursing facilities, assisted living facilities) and no cardiac arrests occurred at the locations where AEDs were most commonly placed (community pools, nongovernment public buildings, schools/educational facilities). CONCLUSION: A poor association exists between the location of cardiac arrests and the location of AEDs. Levy MJ , Seaman KG , Millin MG , Bissell RA , Jenkins JL . A poor association between out-of-hospital cardiac arrest location and public automated external defibrillator placement. Prehosp Disaster Med. 2013;28(4):1-6 .
    Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 05/2013;
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    ABSTRACT: Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted. To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries. Retrospective cohort study involving 223,475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank. Transport by helicopter or ground emergency services to level I or level II trauma centers. Survival to hospital discharge and discharge disposition. A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score-matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001). Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders.
    JAMA The Journal of the American Medical Association 04/2012; 307(15):1602-10. · 29.98 Impact Factor
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    ABSTRACT: Within a healthcare system, operational emergency medical services (EMS) programs provide prehospital emergency care to patients in austere and resource-limited settings. Some of these programs are additionally considered to be wilderness EMS programs, a specialized type of operational EMS program, as they primarily function in a wilderness setting (eg, wilderness search and rescue, ski patrols, water rescue, beach patrols, and cave rescue). Other operational EMS programs include urban search and rescue, air medical support, and tactical law enforcement response. The medical director will help to ensure that the care provided follows protocols that are in accordance with local and state prehospital standards, while accounting for the unique demands and needs of the environment. The operational EMS medical director should be as qualified as possible for the specific team that is being supervised. The medical director should train and operate with the team frequently to be effective. Adequate provision for compensation, liability, and equipment needs to be addressed for an optimal relationship between the medical director and the team.
    Wilderness and Environmental Medicine 03/2012; 23(1):37-43. · 1.49 Impact Factor
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    Michael G Millin, Samiur R Khandker, Alisa Malki
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    ABSTRACT: In the development of an emergency medical services (EMS) system, medical directors should consider the implementation of protocols for the termination of resuscitation (TOR) of nontraumatic cardiopulmonary arrest. Such protocols have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Termination-of-resuscitation protocols for nontraumatic cardiopulmonary arrest should be based on the determination that an EMS provider did not witness the arrest, there is no shockable rhythm identified, and there is no return of spontaneous circulation (ROSC) prior to EMS transport. Further research is needed to determine the need for direct medical oversight in TOR protocols and the duration of resuscitation prior to EMS providers' determining that ROSC will not be achieved. This paper is the resource document to the National Association of EMS Physicians position statement on the termination of resuscitation for nontraumatic cardiopulmonary arrest.
    Prehospital Emergency Care 08/2011; 15(4):547-54. · 1.86 Impact Factor
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    Michael G Millin, Lawrence H Brown, Brian Schwartz
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    ABSTRACT: With increasing demands for emergency medical services (EMS), many EMS jurisdictions are utilizing EMS provider-initiated nontransport policies as a method to offload potentially nonemergent patients from the EMS system. EMS provider determination of medical necessity, resulting in nontransport of patients, has the potential to avert unnecessary emergency department visits. However, EMS systems that utilize these policies must have additional education for the providers, a quality improvement process, and active physician oversight. In addition, EMS provider determination of nontransport for a specific situation should be supported by evidence in the peer-reviewed literature that the practice is safe. Further, EMS systems that do not utilize these programs should not be financially penalized. Payment for EMS services should be based on the prudent layperson standard. EMS systems that do utilize nontransport policies should be appropriately reimbursed, as this represents potential cost savings to the health care system.
    Prehospital Emergency Care 07/2011; 15(4):562-9. · 1.86 Impact Factor
  • Sabina A Braithwaite, Michael G Millin
    The Journal of trauma 07/2011; 71(1):269-70. · 2.35 Impact Factor
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    ABSTRACT: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States. Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature. The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades. This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.
    Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 02/2011; 26(1):49-64.
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    Christina L Catlett, J Lee Jenkins, Michael G Millin
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    ABSTRACT: The National Association of EMS Physicians (NAEMSP) advocates for a strong emergency medical services (EMS) role in all phases of disaster management--preparedness, response, and recovery. Emergency medical services administrators and medical directors should play a leadership role in preparedness activities such as training and education, development of performance metrics, establishment of memoranda of understanding (MOUs), and planning for licensure and liability issues. During both the planning and response phases, EMS leadership should advocate for participation in unified command, modified scope of practice appropriate for providers and the event, and expanded roles in community and federal response efforts. To enhance recovery, EMS leadership should strongly advocate for national recognition for EMS efforts and further research into strategies that foster healthy coping techniques and resiliency in the EMS workforce. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.
    Prehospital Emergency Care 01/2011; 15(3):420-5. · 1.86 Impact Factor
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    ABSTRACT: The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time. Key words: ambulance; EMS; diversion; bypass; offload; delay.
    Prehospital Emergency Care 01/2011; 15(4):555-61. · 1.86 Impact Factor
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    Michael G Millin, Samuel M Galvagno
    World Journal of Surgery 12/2010; 35(5):1152. · 2.23 Impact Factor
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    Prehospital Emergency Care 07/2009; 12(3):395-403. · 1.86 Impact Factor
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    ABSTRACT: Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.
    Prehospital Emergency Care 01/2009; 13(4):516-27. · 1.86 Impact Factor
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    Edbert B Hsu, Michael G Millin
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    ABSTRACT: An influenza pandemic would place an unprecedented strain on the nation's healthcare system-a compelling reason to carefully plan how priorities would be set for distributing antiviral medications. While antiviral medications have been added to the Strategic National Stockpile (SNS), these supplies are not designated as frontline resources and remain far from sufficient to provide mass prophylaxis for the entire population of the country. In the healthcare setting, providing general chemoprophylaxis may not be feasible because of high costs or inadequate supply. We propose a hospital-based strategy for setting priorities for antiviral prophylaxis that may offer a rational starting point for discussion and guide allocation decisions in the event of a shortage during a pandemic influenza outbreak.
    Biosecurity and Bioterrorism 07/2008; 6(2):171-8. · 1.94 Impact Factor
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    ABSTRACT: In recent years, government and hospital disaster planners have recognized the increasing importance of pharmaceutical preparedness for chemical, biological, radiological, nuclear, and explosive (CBRNE) events, as well as other public health emergencies. The development of pharmaceutical surge capacity for immediate use before support from the (US) Strategic National Stockpile (SNS) becomes available is integral to strengthening the preparedness of local healthcare networks. The Pharmaceutical Response Project served as an independent, multidisciplinary collaboration to assess statewide hospital pharmaceutical response capabilities. Surveys of hospital pharmacy directors were conducted to determine pharmaceutical response preparedness to CBRNE threats. All 45 acute care hospitals in Maryland were surveyed, and responses were collected from 80% (36/45). Ninety-two percent (33/36) of hospitals had assessed pharmaceutical inventory with respect to biological agents, 92% (33/36) for chemical agents, and 67% (24/36) for radiological agents. However, only 64% (23/36) of hospitals reported an additional dedicated reserve supply for biological events, 67% (24/36) for chemical events, and 50% (18/36) for radiological events. More than 60% of the hospitals expected to receive assistance from the SNS within < or = 48 hours. From a pharmaceutical perspective, hospitals generally remain under-prepared for CBRNE threats and many expect SNS support before it realistically would be available. Collectively, limited antibiotics and other supplies are available to offer prophylaxis or treatment, suggesting that hospitals may have insufficient pharmaceutical surge supplies for a large-scale event. Although most state hospitals are improving pharmaceutical surge capabilities, further efforts are needed.
    Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 06/2007; 22(3):214-8.
  • Michael G Millin, Travis Gullett, Mohamud R Daya
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    ABSTRACT: The American Heart Association estimates an annual incidence of stroke in the United States at 700,000, leading to over 150,000 deaths. Of all strokes, approximately 88% are ischemic and 12% are hemorrhagic. Almost half of all stroke deaths occur in the out-of-hospital environment. Within a given region, the emergency medical services (EMS) system has an important role in the management of the acute stroke patient. Decisions made by EMS personnel can affect treatment and contribute to the immediate, short-term, and long-term outcomes of the patient. Because the patient may require emergent treatment regardless if the stroke is ischemic or hemorrhagic, EMS personnel should manage all potential stroke patients in a time-dependent nature. Proper treatment and disposition of the stroke patient begins in the out-of-hospital environment, continues in the emergency department, and then extends to the inpatient admission. This article reviews the literature on the out-of-hospital treatment of stroke patients and the role of EMS in the development of stroke systems of care.
    Prehospital Emergency Care 01/2007; 11(3):318-25. · 1.86 Impact Factor
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    ABSTRACT: To review the current literature on the effects of ambulance diversion (AD). The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system.
    Academic Emergency Medicine 12/2006; 13(11):1220-7. · 1.76 Impact Factor
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    ABSTRACT: In the event of a major chemical, biological, radiological, nuclear, or explosive (CBRNE) attack or a natural disaster, large quantities of pharmaceuticals and medical supplies may be required with little or no warning. Pharmaceutical surge capacity for immediate response, before Strategic National Stockpile (SNS) supplies become available, remains a significant gap in emergency preparedness. To date, limited attempts have been made to assess collective regional hospital pharmaceutical response capabilities. In this project, we characterized the level of hospital pharmaceutical response preparedness in a major metropolitan region. The Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR) convened a collaborative partnership to assess hospital pharmaceutical response capabilities. A survey was developed to characterize pharmaceutical response preparedness to CBRNE threats. All 22 acute care hospitals in the Maryland region were sent pharmaceutical response surveys, and responses were received from 86% (19/22). Within the past year, 84% (16/19) of hospitals had implemented an exercise with pharmacy participation. More than half of the hospitals expect to receive assistance from the SNS in 48 hours or less. Seventy-four percent (14/19) of the hospitals reported an additional dedicated reserve supply for biological events, 74% (14/19) for chemical events, and 58% (11/19) for radiological events. Many hospitals in this metropolitan region have taken important steps toward enhancing pharmaceutical preparedness. However, hospitals generally remain underprepared for CBRNE threats and collectively have limited supplies of antibiotics to provide prophylaxis or treatment for hospital staff, their families, and patients in the event of a significant biological incident.
    Biosecurity and Bioterrorism 02/2006; 4(3):237-43. · 1.94 Impact Factor
  • Michael G Millin, Jerris R Hedges, Robert R Bass
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    ABSTRACT: This report examines the complex relationship between the diversion of ambulances within an emergency medical services system and the management of trauma patients.
    Prehospital Emergency Care 01/2006; 10(3):351-4. · 1.86 Impact Factor