Michael G Millin

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (30)79.57 Total impact

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    ABSTRACT: Study objective: Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. Methods: Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. Results: The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. Conclusion: Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes.
    No preview · Article · Oct 2015 · Annals of emergency medicine
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    ABSTRACT: Automated external defibrillators (AEDs) have been used successfully in many populations to improve survival for out-of-hospital cardiac arrest. While ventricular fibrillation and pulseless ventricular tachycardia are more prevalent in adults, these arrhythmias do occur in infants. The Scientific Advisory Council of the American Red Cross reviewed the literature on the use of AEDs in infants in order to make recommendations on use in the population. The Cochrane library and PubMed were searched for studies that included AEDs in infants, any external defibrillation in infants, and simulation studies of algorithms used by AEDs on pediatric arrhythmias. There were 4 studies on the accuracy of AEDs in recognizing pediatric arrhythmias. Case reports (n = 2) demonstrated successful use of AED in infants, and a retrospective review (n = 1) of pediatric pads for AEDs included infants. Six studies addressed defibrillation dosages used. The algorithms used by AEDs had high sensitivity and specificity for pediatric arrhythmias and very rarely recommended a shock inappropriately. The energy doses delivered by AEDs were high, although in the range that have been used in out-of-hospital arrest. In addition, there are data to suggest that 2 to 4 J/kg may not be effective defibrillation doses for many children. In the absence of prompt defibrillation for ventricular fibrillation or pulseless ventricular tachycardia, survival is unlikely. Automated external defibrillators should be used in infants with suspected cardiac arrest, if a manual defibrillator with a trained rescuer is not immediately available. Automated external defibrillators that attenuate the energy dose (eg, via application of pediatric pads) are recommended for infants. If an AED with pediatric pads is not available, the AED with adult pads should be used.
    No preview · Article · Jul 2015 · Pediatric emergency care
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    ABSTRACT: The National Association of Emergency Medical Services Physicians' (NAEMSP) position on the role of medical oversight within an operational Emergency Medical Service (EMS) program highlights the importance of integrating specially trained medical directors within the structure of these programs. In response, the NAEMSP Wilderness EMS (WEMS) Committee recognized the need for the development of an educational curriculum to provide physicians with the unique skills needed to be a medical director for a WEMS agency. This paper describes the Delphi process used to create the subject matter core content, as well as the actual core content developed. This core content was the foundation for the development of a specific WEMS medical director curriculum, the Wilderness EMS Medical Director Course. Copyright © 2014 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Feb 2015 · Wilderness and Environmental Medicine
  • Jonathan Teter · Michael G. Millin · Rick Bissell
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    ABSTRACT: Background. Hospital-acquired infections (HAIs) affect millions of patients annually (World Health Organization. Guidelines on Hand Hygiene in Healthcare. Geneva: WHO Press; 2009). Hand hygiene compliance of clinical staff has been identified by numerous studies as a major contributing factor to HAIs around the world. Infection control and hand hygiene in the prehospital environment can also contribute to patient harm and spread of infections. Emergency medical services (EMS) practitioners are not monitored as closely as hospital personnel in terms of hand hygiene training and compliance. Their ever-changing work environment is less favorable to traditional hospital-based aseptic techniques and education. Methods. This study aimed to determine the current state of hand hygiene practices among EMS providers and to provide recommendations for improving practices in the emergency health services environment. This study was a prospective, observational prevalence study and survey, conducted over a 2-month period. We selected participants from visits to three selected hospital emergency departments in the mid-Atlantic region. There were two data components to the study: a participant survey and hand swabs for pathogenic cultures. Results. This study recruited a total sample of 62 participants. Overall, the study revealed that a significant number of EMS providers (77%) have a heavy bacterial load on their hands after patient care. All levels of providers had a similar distribution of bacterial load. Survey results revealed that few providers perform hand hygiene before (34%) or in between patients (24%), as recommended by the Centers for Disease Control and Prevention guidelines. Conclusion. This study demonstrates that EMS providers are potential vectors of microorganisms if proper hand hygiene is not performed properly. Since EMS providers treat a variety of patients and operate in a variety of environments, providers may be exposed to potentially pathogenic organisms, serving as vectors for the exposure of their patients to these same organisms. Proper application of accepted standards for hand hygiene can help reduce the presence of microbes on provider hands and subsequent transmission to patients and the environment.
    No preview · Article · Nov 2014 · Prehospital Emergency Care
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    ABSTRACT: Introduction Predicting the number of patient encounters and transports during mass gatherings can be challenging. The nature of these events necessitates that proper resources are available to meet the needs that arise. Several prediction models to assist event planners in forecasting medical utilization have been proposed in the literature.Hypothesis/Problem The objective of this study was to determine the accuracy of the Arbon and Hartman models in predicting the number of patient encounters and transportations from the Baltimore Grand Prix (BGP), held in 2011 and 2012. It was hypothesized that the Arbon method, which utilizes regression model-derived equations to estimate, would be more accurate than the Hartman model, which categorizes events into only three discreet severity types.Methods This retrospective analysis of the BGP utilized data collected from an electronic patient tracker system. The actual number of patients evaluated and transported at the BGP was tabulated and compared to the numbers predicted by the two studied models. Several environmental features including weather, crowd attendance, and presence of alcohol were used in the Arbon and Hartman models.Results Approximately 130,000 spectators attended the first event, and approximately 131,000 attended the second. The number of patient encounters per day ranged from 19 to 57 in 2011, and the number of transports from the scene ranged from two to nine. In 2012, the number of patients ranged from 19 to 44 per day, and the number of transports to emergency departments ranged from four to nine. With the exception of one day in 2011, the Arbon model overpredicted the number of encounters. For both events, the Hartman model overpredicted the number of patient encounters. In regard to hospital transports, the Arbon model underpredicted the actual numbers whereas the Hartman model both overpredicted and underpredicted the number of transports from both events, varying by day.Conclusions These findings call attention to the need for the development of a versatile and accurate model that can more accurately predict the number of patient encounters and transports associated with mass-gathering events so that medical needs can be anticipated and sufficient resources can be provided. JV Nable, AM Margolis, BJ Lawner, JM Hirshon, AJ Perricone, SM Galvagno, D Lee, MG Millin, RA Bissell, RL Alcorta. Comparison of prediction models for use of medical resources at urban auto-racing events. Prehosp Disaster Med. 2014;29(6):1-6 .
    No preview · Article · Sep 2014 · 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
  • Chelsea C White Iv · Robert M Domeier · Michael G Millin
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    ABSTRACT: Abstract Field spinal immobilization using a backboard and cervical collar has been standard practice for patients with suspected spine injury since the 1960s. The backboard has been a component of field spinal immobilization despite lack of efficacy evidence. While the backboard is a useful spinal protection tool during extrication, use of backboards is not without risk, as they have been shown to cause respiratory compromise, pain, and pressure sores. Backboards also alter a patient's physical exam, resulting in unnecessary radiographs. Because backboards present known risks, and their value in protecting the spinal cord of an injured patient remains unsubstantiated, they should only be used judiciously. The following provides a discussion of the elements of the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACS-COT) position statement on EMS spinal precautions and the use of the long backboard. This discussion includes items where there is supporting literature and items where additional science is needed.
    No preview · Article · Feb 2014 · Prehospital Emergency Care
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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.
    No preview · Article · Sep 2013
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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.
    Preview · Article · Jul 2013 · Prehospital Emergency Care
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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.
    No preview · Article · May 2013 · 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
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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.
    No preview · Article · Apr 2012 · JAMA The Journal of the American Medical Association
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    Craig R Warden · Michael G Millin · Seth C Hawkins · Richard N Bradley
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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.
    Full-text · Article · Mar 2012 · Wilderness and Environmental Medicine
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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.
    Full-text · Article · Aug 2011 · Prehospital Emergency Care
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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.
    Preview · Article · Aug 2011 · Prehospital Emergency Care
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    Ryan C Jacobsen · Michael G Millin
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    ABSTRACT: Anaphylaxis is a potentially life-threatening condition that requires both prompt recognition and treatment with epinephrine. All levels of emergency medical services (EMS) providers, with appropriate physician oversight, should be able to carry and properly administer epinephrine safely when caring for patients with anaphylaxis. EMS systems and EMS medical directors should develop a mechanism to review the charts of patients who received epinephrine and were not in cardiac arrest. This will help to ensure the safe and appropriate use of epinephrine in order to provide continued quality improvement. Despite the safety of epinephrine, EMS systems that carry epinephrine autoinjectors should establish protocols to deal with patients or emergency responders who have an unintentional injection of epinephrine into the hand or digit. Continued research is needed to better define the role that EMS plays in the management of anaphylaxis. This paper serves as a resource document to the National Association of EMS Physician position on the use of epinephrine for the out-of-hospital treatment of anaphylaxis. Key words: EMS; prehospital; anaphylaxis; epinephrine; intramuscular epinephrine.
    Preview · Article · Aug 2011 · Prehospital Emergency Care
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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.
    Full-text · Article · Jul 2011 · Prehospital Emergency Care
  • Sabina A Braithwaite · Michael G Millin

    No preview · Article · Jul 2011 · The Journal of trauma
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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.
    Full-text · Article · Jun 2011 · Prehospital Emergency Care
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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.
    No preview · Article · Feb 2011 · 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
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    Michael G Millin · Samuel M Galvagno

    Full-text · Article · Dec 2010 · World Journal of Surgery
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    Full-text · Article · Jul 2009 · Prehospital Emergency Care