Aeromedical Research Articles

A data-driven algorithm to support the clinical decision-making of patient extrication following a road traffic collision

BackgroundSome patients involved in a road traffic collision (RTC) are physically entrapped and extrication is required to provide critical interventions. This can be performed either in an expedited way, or in a more controlled manner. In this study we aimed to derive a data-driven extrication algorithm intended to be used as a decision-support tool by on scene emergency service providers to decide on the optimal method of patient extrication from the vehicle.MethodsA retrospective observational study was performed of all trauma patients trapped after an RTC who were attended by a Helicopter Emergency Medical Service (HEMS) in the United Kingdom between March 2013 and December 2021. Variables were identified that were associated with the need for HEMS interventions (as a surrogate for the need for expedited extrication), based on which a practical extrication algorithm was devised.ResultsDuring the study period 12,931 patients were attended, of which 920 were physically trapped. Patients who scored an “A” on the AVPU score (n = 531) rarely required HEMS interventions (3%). Those who did were characterised by a shorter than average (29 vs. 37 min) 999/112 emergency call to HEMS on-scene arrival interval. A third of all patients responding to voice required HEMS interventions. Absence of a patent airway (OR 6.98 [1.74–28.03] p < .001) and the absence of palpable radial pulses (OR 9.99 [2.48–40.18] p < .001) were independently associated with the need for (one or more) HEMS interventions in this group. Patients only responding to pain and unresponsive patients almost invariably needed HEMS interventions post extrication (90% and 86% respectively). Based on these findings, a practical and easy to remember algorithm “APEX” was derived.ConclusionA simple, data-driven algorithm, remembered by the acronym “APEX”, may help emergency service providers on scene to determine the preferred method of extrication for patients who are trapped after a road traffic collision. This has the potential to facilitate earlier recognition of a ‘sick’ critical patient trapped in an RTC, decrease entrapment and extrication time, and may contribute to an improved outcome for these patients.

Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey

ObjectiveHemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users’ experience. MethodsThe study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. ResultsFour of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users’ experience was that PHBPs are beneficial and lifesaving. ConclusionOnly 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.

Inhaled Nitroglycerin for Pulmonary Edema in Air Medical Services: A Retrospective Pilot Study

ObjectiveThe use of traditional inhaled pulmonary vasodilators, such as nitric oxide, to treat symptomatic pulmonary edema is not practical in the air medical or prehospital environment because of difficulty with administration. A hospital-based critical care air medical transport service initiated a pilot study to investigate the use of inhaled nitroglycerin (iNTG) as an alternative pulmonary vasodilator. MethodsFor this pilot study, iNTG was administered using a jet nebulizer setup and concentrated nitroglycerin, both of which are widely available in acute care settings. In conjunction with medical oversight, transport personnel identified patients with respiratory distress secondary to pulmonary edema. Twenty-two months after initiating the protocol, a retrospective chart review was conducted. Data for patients receiving iNTG were retrospectively abstracted through a medical record search and manual chart review. ResultsTwelve patients received iNTG during the pilot study. Basic demographics, medical comorbidities, concurrent medications, laboratory values, and radiographic studies were collected for each patient. Basic statistics were performed to identify any potential trends. ConclusionThe administration of iNTG is feasible in an air medical transport setting and may provide a useful adjunct to treating patients with pulmonary edema and respiratory distress. Because iNTG delivery targets the pulmonary vasculature, this may be of particular benefit in patients with a poor hemodynamic profile. Larger randomized controlled or cohort studies are needed to specifically analyze and compare hemodynamics, diagnostics, and patient outcomes.

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service

ObjectiveDesaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. MethodsThis was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. ResultsDesaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. ConclusionIncreased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

Performance Simulation of Thermodynamic Design for a New Turboshaft Engine

For a search and rescue (SAR) helicopter, the requirements of long-range and twin-engine are becoming increasingly important. In this paper, the overall performance of a new turboshaft engine for SAR helicopters is simulated. Firstly, the main performance parameters of competitor engines are collected and compared, and the thermodynamic cycle parameters of the new engine are proposed subsequently. Then, an engine model is created in Turbomatch and the overall performance of this model at the design point is calculated. Finally, the off-design performances at different conditions of output power, ambient temperature, altitudes and flight Mach numbers (Ma) are investigated. A strategy of variable stator vane (VSV) for the anti-surge control of the axial compressor is also introduced. The results of the performance simulation indicate that this engine is quite competitive with lower specific fuel consumption (SFC) and higher specific power (SP) compared to the current SAR helicopter engines.

Оказание скорой специализированной медицинской помощи и проведение медицинской эвакуации с использованием санитарной авиации в Республике Саха (Якутия) в условиях пандемии Covid-19

Summary. The aim of the study is to investigate the peculiarities of sanitary aviation work in the Republic of Sakha (Yakutia) during the COVID-19 pandemic. Materials and research methods. The subject of the study is the work of the Disaster Medicine Service of the Republic of Sakha (Yakutia); the object of the study is the volume and structure of sanitary tasks performed during the spread of the new coronavirus infection COVID-19. Research methods were analytical methods, methods of expert evaluation and mathematical analysis. Results of the study and their analysis. A comparative analysis of the main performance indicators of the Republican Center for Disaster Medicine of the Republic of Sakha (Yakutia) in 2020-2022 is presented. The results of the study indicate that during the spread of a new coronavirus infection COVID-19 the air ambulance service of the Republic worked with increased workload. Under the conditions of COVID-19 pandemic, emergency medical care and medical evacuation of not only patients with severe form of new coronavirus infection, but also of patients with other nosologic forms of diseases requiring emergency medical intervention were provided. The conclusion about the acute urgency of using sanitary aviation in vast sparsely populated areas of other regions is made.

Вектор развития санитарной авиации в Республике Дагестан: история и современность, к 85-летию службы санавиации Дагестана

Summary. The history of creation (1938) and formation of sanitary aviation service in the Republic of Dagestan is presented. The problems faced by the pioneers and enthusiasts of “winged ambulance” are considered. The priority of this branch in the structure of emergency medicine of Dagestan, a significant part (25.5 thousand km2) of which territory is occupied by mountains, is noted. It is concluded that the urgency of the problem of further development of air ambulance in Dagestan is conditioned by its priority and efficiency in the structure of emergency medicine, as it allows to promptly provide patients from hard-to-reach areas with differentiated specialized medical care in multidisciplinary hospitals.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm

ObjectiveLimited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. MethodsWe performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. ResultsDetailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. ConclusionsHypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types

ObjectiveTreating traumatic hemorrhage is time sensitive. Prehospital care and transport modes (eg, helicopter and ground) may influence in-hospital events. We hypothesized that prehospital time (on-scene time [OST] and total prehospital time [TPT]) and transport mode are associated with same-day transfusion and mortality. Furthermore, we sought to identify regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. MethodsWe obtained prehospital, in-hospital, and trauma registry data from an 8-center cohort of adult nonburn trauma patients from 2017 to 2022 directly transported from the scene to the hospital and having an Injury Severity Score (ISS) > 9 for the Task Order 1 project of the Linking Investigators in Trauma and Emergency Services research network. We excluded patients missing prehospital times, patients < 18 years of age, patients from interfacility transfers, and recipients of prehospital blood. Our same-day outcomes were in-hospital transfusions within 4 hours and 24-hour mortality. Each outcome was adjusted using multivariable logistic regression for covariates of prehospital phases (OST and TPT), mode of transport (helicopter and ground), age, sex, ISS, Glasgow Coma Scale motor subscale score < 6, and field hypotension (systolic blood pressure < 90 mm Hg). We evaluated the association of prehospital time on outcomes for scene missions by transport mode across severe injury patterns defined by Abbreviated Injury Scale > 2 body regions. ResultsOf 78,198 subjects, 34,504 were eligible for the study with a mean age of 47.6 ± 20.3 years, ISS of 18 ± 11, OST of 15.9 ± 9.5 minutes, and TPT of 48.7 ± 20.3 minutes. Adjusted for injury severity and demographic factors, transport type significantly modified the relationship between prehospital time and outcomes. The association of OST and TPT with the odds of 4-hour transfusion was absent for the ground emergency medical services (GEMS) cohort and present for the helicopter emergency medical services (HEMS) ambulance cohort, whereas these times were associated with decreased 24-hour mortality for both transport types. When stratifying by injury to most anatomic regions, OST and TPT were associated with a decreased need for 4-hour transfusions in the GEMS cohort. However, OST was associated with increased early transfusion only among patients with severe injuries of the thorax, and this association persisted after adjusting additionally for injury type (odds ratio [OR] = 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02). The presence of polytrauma supported an association between prehospital time and decreased 24-hour mortality for the GEMS cohort (OST: OR = 0.97; 95% CI, 0.95-0.99; P < .01; TPT: OR = 0.99; 95% CI, 0.98-0.99; P = .02), whereas no injuries showed significant association of helicopter prehospital time on mortality after adjustment. ConclusionWe determined that transport type affects the relationship between prehospital time and hospital outcomes (4-hour transfusion: positive relationship for HEMS and negative for GEMS, 24-hour mortality: negative for both transport types). Furthermore, we identified regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. Of these regions, most notable were severe isolated injuries to the thorax that supported a positive relationship between HEMS OST and 4-hour transfusions and polytrauma that showed a negative relationship between GEMS OST or TPT and 24-hour mortality after adjustment.

Patients at Risk for Transfusion—A Six-Year Multicentre Analysis of More Than 320,000 Helicopter Emergency Medical Service Missions

Background. In Europe, ambulances are increasingly being equipped with blood products for prehospital use. Available evidence on the early administration of blood products comes from military medicine and the Anglo-American medical literature; the evidence cannot be easily transferred to European countries. Objectives. This study assesses the incidence of patients with massive haemorrhage after trauma and the potential need for prehospital blood transfusions. Methods. Data reported by 37 German air rescue stations between 2015 and 2020 were retrospectively analysed to predict the need for massive transfusion. Results. A total of 320,347 helicopter emergency medical service (HEMS) missions were performed and involved 2982 patients with potential need for massive transfusion after trauma (approximately 13 transfusions per helicopter per year). Men were most affected (73%). The median age of patients was 38 years. Traffic accidents accounted for 59% of the cases. Most patients sustained multiple injuries including traumatic brain injuries (62%), as well as thoracic (54%), abdominal (39%), and extremity injuries (41%). The median “rSIG” (reversed shock index multiplied with the Glasgow Coma Scale) decreased from 4.31 to 3.78. Conclusions. Although the incidence of haemorrhagic trauma patients is low, the prehospital administration of blood products might be useful as a potentially life-saving bridging treatment until hospital admission.

Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study

ObjectiveInterhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. MethodsThis was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. ResultsA total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. ConclusionGeographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

Arrhythmias Occurring in Children during HEMS Intervention: A Retrospective Cohort Study.

Arrhythmias in patients during medical transport remain a challenge for medical personnel. Helicopter emergency medical service (HEMS) crews, as the only medical rescue teams in Poland to conduct rescue flights, keep detailed documentation of monitoring vital functions over short time intervals during the flight. The aim of this study was to determine the characteristics of cardiac arrhythmia in pediatric patients (up to 12 years of age) transported by HEMS operatives, considering life-threatening rhythms and those that occur during out-of-hospital cardiac arrest (OHCA). The analysis of HEMS medical documentation covered 90345 missions carried out from 2011 to 2020. Among all activations, 820 cases of arrhythmias in pediatric patients up to 12 years of age were extracted. Missions for males accounted for 60% of all activations (n = 492), while flights for females accounted for 40% (n = 328). A statistically significant relationship between the number of HEMS flights and the season was demonstrated (p = 0.015). During the study period, pediatric patients mostly experienced cardiac arrhythmias in the form of supraventricular tachycardia (sVT) (n = 504). Asystole (n = 178) and pulseless electrical activity (PEA) (n = 52) ranked second and third in terms of occurrence, respectively. A statistically significant relationship between the type of heart rhythm disorder and age was demonstrated (p < 0.05). Heart rhythm disorders most often affected children between 0 and 3 years of age. As the patient's age increased, the incidence of arrhythmias decreased. Among pediatric patients, supraventricular tachycardia proved to be the predominant arrhythmia during the study period.

Description of the prehospital emergency healthcare system in Norway

BackgroundNorway has a long coastline, steep mountains, and wide fjords, which presents some challenges to the prehospital emergency healthcare system. In recent years, the prehospital emergency medical services (EMS) have undergone significant changes, structurally, in terms of professionalisation of the services and in the education level of the personnel. In this article, we aim to describe the current structure for handling prehospital medical emergencies. MethodsFor healthcare, Norway is divided into four Regional Health Authorities, consisting of 19 Health Trusts, where 18 have an EMS. There is a dedicated medical emergency number, 113, that terminates in 16 emergency medical communication centres. The use of air and boat ambulances, in addition to traditional ambulances, seeks to meet the challenges in the EMS system. Strengths and limitationsThe Norwegian EMS is an advanced system with highly educated staff; however, this level of care comes with an equally high cost. ConclusionThe Norwegian EMS can handle emergencies nationwide, providing advanced care at the scene and during transport. The geography and demography challenge the idea of equal care, but the open publishing of data from national quality registries seeks to identify and address potential differences.

Challenges for the Routine Application of Drones in Healthcare: A Scoping Review

Uncrewed aerial vehicles (UAVs), commonly known as drones, have emerged as transformative tools in the healthcare sector, offering the potential to revolutionize medical logistics, emergency response, and patient care. This scoping review provides a comprehensive exploration of the diverse applications of drones in healthcare, addressing critical gaps in existing literature. While previous reviews have primarily focused on specific facets of drone technology within the medical field, this study offers a holistic perspective, encompassing a wide range of potential healthcare applications. The review categorizes and analyzes the literature according to key domains, including the transport of biomedical goods, automated external defibrillator (AED) delivery, healthcare logistics, air ambulance services, and various other medical applications. It also examines public acceptance and the regulatory framework surrounding medical drone services. Despite advancements, critical knowledge gaps persist, particularly in understanding the intricate interplay between technological challenges, the existing regulatory framework, and societal acceptance. This review highlights the need for the extensive validation of cost-effective business cases, the development of control techniques that can address time and resource savings within the constraints of real-life scenarios, the design of crash-protected containers, and the establishment of corresponding tests and standards to demonstrate their conformity.

“The Pit and the Pendulum” Inspires Medical Evacuation Helicopter Rescue Approaches

“The Pit and the Pendulum” Inspires Medical Evacuation Helicopter Rescue Approaches

The SWiFT trial (Study of Whole Blood in Frontline Trauma)—the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial

BackgroundEarly blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h.MethodsThis is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants—after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848).DiscussionThe SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting.Trial registrationISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.

Factors affecting the preparedness of Helicopter Emergency Medical Services (HEMS) in disasters: a systematic review

BackgroundOne of the most significant advantages of Helicopter Emergency Medical Service (HEMS) in disaster relief efforts is their ability to reach inaccessible or remote areas quickly. This is especially important in the aftermath of natural disasters such as earthquakes, floods, or hurricanes, where roads may be blocked or damaged, and conventional ground transportation may not be available. There are many factors can affect the performance of Helicopter Emergency Medical Service (HEMS) in disasters. This study aims to investigate the factors affecting the Helicopter Emergency Medical Service (HEMS) in disasters.MethodsThe systematic search in Cochran Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest, and Google Scholar databases between the first of January in 1975 and the thirty-first of May in 2023. The articles were selected based on the keywords of the authors. At last, the criteria were extracted from the selected ones.ResultsThe primary search included 839 articles. After studying their title, abstract, and full context, only nine articles, including two qualitative and seven quantitative ones, were chosen for analysis. After analysis and extracting data from the final studies, the preparation factors were categorized into 6 general classes of human resources: training and practicing, management, instructions and standards, equipment, and structure. Among these, the role of training is highlighted by holding practice and maneuvers to improve and prepare the personnel and manage disasters and incidents.ConclusionThe results obtained from this systematic review provide a total view of the factors affecting the preparation of the air ambulance during disasters and incidents. It is recommended that senior managers and policy makers use the findings of the present study to identify the factors which affect preparedness of HEMS in disasters and take the necessary measures to eliminate to obstacles.

Abstract 15775: Prehospital Scene Delays in the Prehospital Care of ST-Segment Myocardial Infarction (STEMI)

Introduction: Emergency medical services (EMS) are an important link in the chain of care for patients experiencing time-sensitive cardiovascular emergencies, including ST-segment elevation myocardial infarction (STEMI). Recent quality initiatives have focused on reducing delays in STEMI care in both the prehospital and in-hospital environments. For instance, “door-to-balloon times” are tracked to ensure minimal delays from the time a STEMI patient enters a hospital to revascularization. In the prehospital realm, comparably less research has investigated factors contributing to delays in care for STEMI patients. Prolonged “scene times” - the time spent with a patient prior to transport - represents one area where focus is needed. Methods: As part of an ongoing initiative, EMS providers are encouraged to limit scene times to under 20 minutes for STEMI patients. We queried data from the Minnesota State Emergency Medical Services Regulatory Bureau (EMSRB) to ascertain what percentage of EMS encounters involving STEMI patients within the state’s MNSTAR EMS database between 2018 and 2021 had a scene time of greater than 20 minutes. Encounters involving helicopter emergency medical services (HEMS) were excluded. Results: Between 2018 and 2021, there were a total of 5178 STEMI patient encounters meeting eligibility criteria. Approximately 67.6% (n~3501) of patient encounters involved a scene time less than or equal to 20 minutes. Rural communities were associated with prolonged scene times when compared with metropolitan communities. Conclusions: Our preliminary analysis of EMS data from Minnesota shows one-third of STEMI encounters had scene times greater than 20 minutes. Thus, reducing prehospital scene times by EMS may be one method to streamline the care for STEMI patients. Further research should investigate what factors influence EMS crews to spend more than 20 minutes on scene with STEMI patients.

Tiger attack at a Japanese safari park: a case report

BackgroundBig cat bites are highly lethal due to the enormous bite force of these animals. This article reviews the morphology of these types of injuries and key points of management through a survival case at a Japanese safari park.Case presentationWe report the case of a 26-year-old female keeper who was attacked by a tiger. She was quickly transported to our university hospital by ambulance helicopter. The keeper was severely bitten on the head and face and had wounds all over her body. Craniofacial repair was performed by emergency surgery. She suffered mild facial nerve paralysis and trismus because of being bitten by the tiger and is currently recovering.ConclusionsA multidisciplinary approach of the severe tiger bites successfully treated a young woman cosmetically and mentally. Animal farms and zoos that keep tigers should take strict measures to avoid direct confrontation with tigers.

Fatigue risk assessment of a Helicopter Emergency Medical Service crew working a 24/7 shift pattern: results of a prospective service evaluation

BackgroundThe work of Helicopter Emergency Medical Services (HEMS) teams crosses the boundaries of several high-risk occupations including medicine, aviation, and transport. Working conditions can be challenging and operational demands requires a 24-h rota, resulting in disruption of the normal circadian rhythm. HEMS crews are therefore prone to both mental and physical fatigue. As fatigue in medical providers is linked to poor cognitive performance, degradation of psychomotor skills and error, this study aimed to explore the existence of predictable patterns of crew-fatigue in a HEMS service.MethodsHEMS medical crew members working a 3-on 3-off forward rotating rota with a 5-week shift cycle were asked to do psychomotor vigilance tests (PVT) as an objective measure of fatigue. PVT testing was undertaken at the start, mid- and at the end of every shift during a full 5-week shift cycle. In addition, they were asked to score subjective tiredness with the Samn-Perelli Fatigue Scale (SPFS), and to keep a Transport Fatigue Assessment shift log, wherein they noted shift characteristics potentially related to fatigue. Primary outcome of interest was defined as the change in PVT and SPFS scores over time.ResultsMean baseline resting PVT in milliseconds at the start of the study period was 427 [390–464]. There was an overall trend towards higher PVT-scores with shift progression mean [95% CI] PVT at the start of shifts 447 [433–460]; halfway through the shift 452 [440–463]; end of the shift 459 [444–475], p = 0.10), whereas SPFS scores remained constant. Within a 5 week forward-rotating cycle, an overall trend towards a gradual increase in both average PVT (from 436 [238–454] to 460 [371–527, p = 0.68] ms;) and SPFS (from 2.9 [2.6–3.2] to 3.6 [3.1–4.0], p = 0.38) was observed, although significant interindividual variation was present. Reported SPFS scores ≥ 4 (moderate fatigue) were mainly related to workload (number of jobs) and transport mode (car-based shifts).ConclusionAn overall trend towards a decline in psychomotor vigilance and an increase in self-reported tiredness was found for HEMS crew over a 5-week shift cycle. Using a bespoke predictive fatigue tool on a day-to-day basis could increase fatigue awareness and provide a framework to which relevant mitigating options can be applied.