Medical Emergency Response Team Research Articles

Transport of Patients With High-Consequence Infectious Diseases: Development of European Capacity in Norway.

Infection of Western aid workers with Ebola virus disease during the 2014-2016 West African outbreak demonstrated the need for medical evacuation to high-level isolation units in Europe and the United States. In Norway, an ad hoc preparedness team was established for aeromedical evacuation in case of need. In October 2014, this team transported an infected aid worker from the military section of Oslo Airport to Oslo University Hospital. To maintain and strengthen the capacity for domestic ambulance transport on the ground and in the air, the Norwegian Medical Emergency Response Team for High Consequence Infectious Diseases (in Norway known as "Nasjonalt medisinsk utrykningsteam for høyrisikosmitte"), or NORTH, was established as a permanent service in 2017. Recognizing the expertise of this domestic team, Norway was subsequently entrusted with the task of enhancing the European aeromedical transport capacity for high-consequence infectious diseases and establishing the Norwegian rescEU Jet Air Ambulance for Transport of Highly Infectious Patients, or NOJAHIP, in 2022. In this case study, we present experiences and lessons learned from these 2 services and discuss how they can be further developed.

Improving Medical Emergency Team Response Time for Urgent Care Patients in Primary Health Care Centers, Riyadh, Saudi Arabia

Background: Emergency healthcare systems are of increasing concern in international healthcare developments and the global fight against the burdens of disease. Concerns about focusing on ambulance response time as a single indicator are addressed by showing a case-sensitive approach for developing emergency health care systems that in return can identify ambulance response as the main indicator for a particular system. Problem description: Data collected by monitoring the time of receiving the call at the ambulance division until transport time.Methods: The fishbone diagram is used as a tool for understanding the process variation, investigate and eliminating unusual occurrences by the following methodology: M.M.M.Main outcomes: Responding time in emergency cases not exceeding 5 minutes; To improve responding time; To improve types of communication; To improve compliance with the logbook of the emergency referred cases. The intervention plan was Continuous Training for the staff and Clear Guidelines for emergency calls. Review and assess the actual implementation of the project. Data will be collected by an Emergency Medical specialist. A copy of the data should be sent to CQI for a continuous monitoring process. Check the data for process improvement (incident report analysis). Document the results of the change. Modify the change, if necessary and possible. The Emergency Medical Technicians quality coordinator will check the Data. Continue improvement by close monitoring of the compliance.Results: the mean response time dropped from 15 minutes in January 2023 to less than 5 minutes in December 2023.Conclusion: this initiative positively impacts the emergency team's response time and improves patient satisfaction. Response time reduction was evident, and the quality of the health care service was improved. Reduction of response time also improved emergency preparedness

Blood far forward: A cross-sectional analysis of prehospital transfusion practices in the Canadian Armed Forces

BackgroundCanadian Armed Forces (CAF) operate in environments that challenge patient care, especially trauma. Military personnel often find themselves in remote settings without conventional healthcare facilities. Treating traumatic injuries, particularly hemorrhagic shock, often necessitates prehospital blood transfusion. This study aims to present an overview of the current CAF prehospital transfusion practices. Furthermore, the study compared current and developing protocols against expert-recommended guidelines. MethodsA cross-sectional survey design was employed to describe and compare CAF prehospital blood transfusion practices and protocols against expert recommendations. Topics included protocols, equipment, and procedures. An online survey targeted medical leadership and providers within CAF, with data collected from August 15 to December 15, 2023. Results were summarized descriptively. This study received approval from the Unity Health Toronto Research Ethics Board (REB 23–087). ResultsUnits and teams with prehospital blood transfusion capabilities were contacted, achieving a 100 % response rate. Within CAF, Canadian Special Operations Forces Command (CANSOFCOM), Mobile Surgical Resuscitation Team (MSRT), and Canadian Medical Emergency Response Team (CMERT) possess these capabilities, established between 2013 and 2018. These programs are crucial for military operations. CAF has access to standard blood components, cold Leuko-Reduced Whole Blood (LrWB), and factor concentrates from Canadian Blood Services (CBS), available for both domestic and international missions given adequate planning and favorable conditions. Key findings indicate high adherence to recommended practices, some variability in the transfusion process, and potential benefits of standardizing prehospital transfusion practices. ConclusionsThis study provided insights into CAF's implementation of prehospital transfusion practices, highlighting high adherence to national expert recommendations and the importance of structured protocols in military prehospital trauma management. Implications of key findingsCAF's approach and adoption of prehospital transfusion protocols lay a strong foundation for managing trauma patients in remote settings and for expanding prehospital transfusion capabilities across CFHS deployed assets. Further research is needed to advance military trauma care by adapting prehospital blood transfusion to dynamic tactical landscapes and evolving technologies.

Improving patient outcomes following vital sign monitoring protocol failure: A retrospective cohort study.

Vital sign monitoring needs to be timely and correct to recognize deteriorating patients early and trigger the relevant clinical response. The aim of this study is to retrospectively evaluate compliance specifically toward the regional vital sign monitoring protocol the so called early warning score protocol (EWS-protocol) 72 h before a medical emergency team response (MET-response) and thereby illuminate whether poor compliance translates into a worse patient outcome. It was investigated all eligible patients that underwentMETresponses during the calendar year 2019. The inclusion criteria encompassed somatic patients above 18 years of age admitted to the hospital and detailed evaluations of the medical records of the included patients were conducted. Four hundred and twenty-nineMET-responses were included in the final analysis. EWS-protocol failure was observed for more than half the patients within all the time frames assessed. Thirty-day mortality was significantly higher for patients subject to EWS protocol failure in the timeframes 24-16, 16-8, 8-0 h before MET response. Adjusting for admission length, age, and gender, patients subject to EWS-protocol failure had an odds ratio (OR) of 1.9, 2.0, 2.1, 2.3 for mortality in the time frames 72-48, 24-16, 16-8, and 8-0 h before the MET-response, respectively. The adjusted OR for ICU-admission was 1.7, and 1.6 for patients subject to EWS-protocol failure in the time frames 16-8and 8-0 h before MET-response, respectively. According to all the data analysis in this article, there is evidence that compliance towardthe NEWS-protocol is poor. EWS-protocol failure is associated with a significant higher mortality and ICU-admission rate.

High value healthcare analysis of “triggers” in deteriorating patients

Objective: To review “triggers” for deteriorating patients who required intervention by a medical emergency response team (MET). In addition, to assess whether these “triggers” differed by medical or surgical governance of these patients. A secondary objective was to report laboratory investigations performed via the MET, with particular interest in tests duplicating haemoglobin (Hb) values and their degree of concordance within the context of low-cost, high value inpatient care.Methods: This quality improvement initiative involved a prospective observational cohort of inpatients, who were attended to by the MET at Royal Perth Hospital in Perth, Western Australia over a 2-year period between 2020 and 2022.Results: The mean number of MET calls for inpatients under surgical governance was slightly higher than for those patients under medical governance (1.34 vs. 1.25 calls respectively p = .03). Hypotension triggered a MET call in 184 (40.9%) surgical patients compared to 154 (28%) under medical governance (p < .001). Comparing haemoglobin values obtained from FBP and VBG, Lin’s concordance correlation coefficient (CCC) was found to be 0.986, 95%CI: 0.983, 0.989. The Bland-Altman limits of agreement suggest that the haemoglobin value on a VBG ranges from 9.55 g/L higher than the FBP to 4.7 g/L lower than the FBP.Conclusions: Significant differences in the frequency of triggers for patients under medical vs surgical governance highlight the need for proactive planning around hypotension management of patients under surgical governance. In addition, understanding the nuances between haemoglobin values obtained from FBP and VBG can help with value-based health care and efficiencies in patient care, since measuring haemoglobin values is one of the key components in hypotension management.

Preparation of Medical Supply for Prehospital Emergencies and Disasters: An Internet-Based Simulation Drill.

Mass casualties caused by natural disasters and man-made events may overwhelm local emergency medical services and healthcare systems. Logistics is essential to a successful emergency medical response. Drills have been used in disaster preparedness to validate plans, policies, procedures, and agreements, and identify resource gaps. The application of the internet to facilitate the conduct of exercise was still limited. This study aimed to investigate the optimal preparation of medical supplies by medical emergency response teams (MERTs) during emergencies and disasters using an internet-based drill. An internet-based drill based on real-life mass casualty incidents (MCIs) was developed and conducted in Taiwan from June 2017 to July 2018. The drill involved an MCI with 50 events delivered under two scenarios: (1) reduced transfer capacity and well-functioning local healthcare facilities (emergency module); (2) severely reduced transfer capacity and dysfunctional local healthcare facilities (disaster module). For each event, medical supplies commonly prepared by local MERTs in Taiwan were listed in structured questionnaires and participants selected the supplies they would use. Forty-three senior medical emergency responders participated in the survey (responding rate of 47.3%). Resuscitation-related supplies increased from emergency to disaster module (e.g., intubation from 9.1% to 13.9%; dopamine from 3.2% to 5.0%; all p < 0.001). In the subgroup analysis of events with life-threatening injuries, the utilization of resuscitation-related supplies (e.g., intubation from 46.6% to 65.3%; p < 0.001) remained higher in the disaster than in the emergency module. Compared to emergency medical technicians, physicians and nurses are more likely to use intravenous/intramuscular analgesics. The severity of scenarios and the professional background of emergency responders have a different utilization of medical supplies in the simulation drill. The internet-based drill may contribute to optimizing the preparedness of medical response to prehospital emergencies and disasters.

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study

Background The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed. Objective To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE. Design & Setting We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient. Results A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944–0.988], p 0.003). Conclusion An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Successful Debriefs Result in an Medical Emergency Response Team Alerting Tool

The debrief process as we know it consists of very short informal feedback sessions that occur immediately after events and are designed to identify opportunities to improve teamwork skills and outcomes. The staff at Baylor University Medical center realized through results of the debrief process that there were not enough hands in the room, there was a need for consistent language, and the charge nurse was not always aware of emergent situations. Implementation of the debrief process for unexpected events proved to be successful in our facility; however, staff buy-in remained challenging.

The high impulse, palm lift technique for chest compression: Prospective, experimental, pilot study.

The classic technique of high quality chest compression (HQCC) during cardiopulmonary resuscitation (CPR) is based on the International Liaison Committee on Resuscitation (ILCOR) guidelines which specify that the rescuer's hands should maintain constant contact with the chest surface but should not lean upon it, in order to provide full chest recoil. Since end-tidal CO2 (EtCO2) values have been shown to be a reliable indicator of CPR quality, we examined a method where classic HQCC was modified by a high impulse and palm lifting (HIPL) technique which merged rapid forceful compression with disconnection of the rescuer's palm from the patient's sternum during the recoil phase. The object of the study was to detect any differences in HIPL EtCO2 values in comparison with those from classic HQCC. We report a prospective pilot study in which we compared EtCO2 readings achieved during 2min of classic HQCC technique with readings after implementing 2min of the HIPL technique during out-of-hospital CPR, provided by medical emergency response teams for cases of cardiac arrest. EtCO2 values obtained from16 cases who received HQCC followed by HIPL compressions showed a significant difference (p=0.037) between the two techniques. Mean±SD EtCO2 values after 2min of each technique were: HQCC: 18±9mmHg; HIPL: 27±11mmHg; followed by a further 2min of HQCC: 19±11mmHg. Linear regression showed that the differences in EtCO2 were associated with non - significant changes in ventilation rate (p=0.493) and chest compression rate (p=0.889). The results obtained suggest that modifying HQCC with the HIPL technique led to a significant increase in EtCO2 values in comparison with classic HQCC, indicating an improvement in circulation during CPR. We think that these encouraging early results warrant a larger multi - centre study of HIPL.

Evaluation of inpatient oxygen therapy in hypercapnic chronic obstructive pulmonary disease.

High concentration oxygen therapy in hypercapnic chronic obstructive pulmonary disease (COPD) is associated with increased mortality. In ward-based patients with acute exacerbation of COPD and hypercapnia, this study examines oxygen prescription and the association between high concentration oxygen therapy and adverse outcome. To investigate the association between over-oxygenation and in-hospital adverse events. Inpatients with acute exacerbation of hypercapnic COPD at a tertiary Australian hospital over a 1-year period were retrospectively identified. Oxygen prescription and therapy was determined based on chart review. Over-oxygenation was defined as ≥10% of nursing chart observations recording oxygen delivery with oxygen saturation above 92%. A composite adverse outcome was defined as medical emergency team response, recommencement of non-invasive ventilation or death. The association between over-oxygenation and adverse outcome was assessed using survival analysis and conditional logistic regression modelling. The study cohort comprised 106 unique patients and 157 admissions. Oxygen prescription was recorded in 132 (84%) and over-oxygenation occurred in 97 (62%) admissions. Over-oxygenation was higher in non-respiratory ward admissions (76% vs 57%, P = 0.03) and those without any form of oxygen prescription (84% vs 58%, P = 0.01). During follow up, 23 (22%) patients experienced an adverse event. Cox proportional hazards modelling found weak evidence for increased risk of an adverse event in over-oxygenated patients (hazard ratio 2.5; 95% confidence interval 0.8-7.3, P = 0.10). Conditional logistic regression, after matching on age, Charlson comorbidity category and length of follow up, found a similar estimate of association (hazard ratio 2.6; 95% confidence interval 0.8-8.7, P = 0.12). Over-oxygenation to hypercapnic COPD inpatients is common and rates of oxygen prescription are suboptimal. We found weak evidence of association between over-oxygenation and adverse events, likely due to low statistical power. Larger prospective studies are needed.

Care of Older People in Surgery for general surgery: a single centre experience.

Older patients undergoing emergency surgery experience higher mortality and morbidity. 'Care of Older People in Surgery' (COPS) is a comprehensive geriatric care model developed for acute surgical units (ASU) to improve clinical outcomes in older general surgical patients. This study aimed to evaluate the impact of COPS on clinical and health service outcomes in an Australian hospital. The before-and-after study was conducted in the ASU, at Nepean Hospital. Data from patients ≥75 years admitted for >24 h into the ASU during the intervention period between April 2017 and March 2018 were compared to patients admitted in the previous year (April 2016 to March 2017) prior to the COPS intervention (n=212). Health service outcomes measured include the average stay length, medical emergency team response, unplanned intensive care unit admission and 28-day readmission rates. The COPS group (n=214) suffered significantly fewer medical complications, including less acute kidney injuries, arrhythmias and urinary tract infections compared to the pre-intervention cohort (n=212). Medical emergency team activation was significantly reduced after COPS model implementation and the average length of stay decreased. However, the incidence of postoperative delirium and acute coronary syndrome were higher in COPS cohort. Our study demonstrated that comprehensive geriatric assessment and care delivered through a shared model of care in older general surgical patients improved clinical outcome and patient safety measures.

A qualitative study to investigate the psychosocial effects of operational deployments on Medical Emergency Response Team personnel.

The stressors associated with emergency medical teams responding to critical incidents are well documented; however, the impact of such duties on the UK military personnel had never been investigated. This study explored the psychosocial effects of Medical Emergency Response Teams (MERT) operating in Afghanistan to inform the development of a Resilience Model. A structured and contextually relevant process could then be applied for a team's preparation for, delivery of and recovery from, their duties. A qualitative cross-sectional design used semi-structured interviews and 15 multidisciplinary team members participated. Interviews were transcribed verbatim and data were systematically analysed using grounded theory. Emergent theory poses that developing resilience against the demands of this role is dependent upon personnel having a realistic understanding of the deployed environment by phased immersion within it. This preparatory training generates situational awareness, trust and strong team cohesion, which together with peer and organizational support are necessary factors to effectively cope with the role. To limit the costs of caring, there is a need for MERT personnel to segregate the physiological and emotional aspects of delivering care to the injured; those unable to do so may be at greater risk of poor mental health outcomes. The preparatory training of MERT personnel must be further developed to provide an immersive environment that more closely matches the reality of the role. A period of stability is required post deployment with the support of peers to enable personnel to more efficiently transition back to their home life.

A comparison of handover communication in NHS and military emergency care

Background: There is a gap in the literature comparing communication during handover between military and NHS emergency care settings. Objectives: This study aimed to explore differences in handover communication in the NHS and the military, and to understand how paramedics manage the transition between settings. Design: This was a qualitative study for which 13 paramedics were interviewed. It focused on handover communication in NHS emergency care settings and Camp Bastion Hospital, Afghanistan. Methods: Interviews were conducted with regular and reservist paramedics serving in the Royal Air Force who had undertaken a deployment with the Medical Emergency Response Team. Semi-structured interviews were recorded, transcribed, coded and subjected to a thematic analysis. Results: Three principal themes were identified: differences between handover communication; standardisation; and the challenge of transition. Conclusion: Participants were most concerned about standardisation. Transition theory and resilience may account for the difficulties encountered when transitioning between different care settings.

A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study.

BackgroundAlthough the evidence for its effectiveness remains uncertainty, rapid response systems are implemented across many hospitals across the world. Increasingly, hospitals in China have recently started to adopt a medical emergency or rapid response team (RRT). Hence, we aimed to determine whether the implementation of an RRT in Chinese hospitals also improved outcomes.MethodsOur hospital is a Joint Commission International (JCI) accredited, tertiary teaching hospital with 1,200 beds. We conducted a retrospective cohort study comparing 60 months after the implementation of the RRT (January 1, 2013, to December 31, 2017) and 36 months before implementation (January 1, 2009, to December 31, 2011). The outcomes included the overall hospital mortality and incidence of codes.ResultsWe analyzed 144,673 non-obstetric hospital admissions and 1,269,621 patient days in the control period and 348,687 non-obstetric hospital admissions and 2,361,913 patient days after the RRT implementation. The RRT was activated 834 times (2.39 calls per 1,000 patients and 0.35 call per 1,000 patient-days). There was no difference in the code rate (0.23 vs. 0.17 per 1,000 patient days, P=0.379) between the two periods. Although the hospital mortality had remained stable around 3.0 per 1,000 patients from 2009 to 2011, there was a significant 40% decrease of overall hospital mortality from 2.95 to 1.77 per 1,000 non-obstetric patients after the implementation of RRT (P=0.001), and the annual mortality showed a consistent decrease (P=0.037 for the trend). Moreover, the increase of RRT activations was significantly correlated with the decrease of hospital mortality (P=0.025).ConclusionsRRT implementation was associated with reduced overall hospital mortality in a Chinese tertiary hospital.

Medical emergency response training. Can we make a difference?

Introduction: In the last year, clinically deteriorating patients triggered 3700 Medical Emergency Response Team (MERT) activations in a tertiary hospital. The responding team consists of junior doctors from intensive care and medicine and nursing staff. Training deficits have been identified in confidential surveys completed annually by 74 specialists and 210 team responders since 2017. Of the responding MERT team 139 (66%) had less than 3 years’ clinical experience, 181 (86%) had felt inadequately prepared attending a MER and 193 (92%) requested more training. A MERT course commenced in 2019 endorsed by the governance committee for acute deterioration, addressing National Standard Eight and CICM minimum standards for training. Objectives/Aims: To improve clinician confidence and ability to manage clinical deterioration by introducing a 1-day simulation based MERT course focusing on enhancing technical and non-technical skills. Methods: Doctors completed post-course evaluation forms and global staff surveys were completed from 2017-2019. Results: Post course evaluation reported 35 (100%) of participants enjoyed the course, identified clear learning objectives, reported improved knowledge. All participants felt more confident managing a MER and that it had changed their practice. Thirty-four (97.5%) would recommend the course to others. After commencing the course, the global staff survey demonstrated the number of trainees requesting training fell from 92% to 64% post (p=<0.001). Reported bedside conflict post-course halved from 66% to 34%, with fewer triggers for conflict 2.8 from 4.7 per responder (Likert scale 1-4) p=<0.001. Barriers to escalation fell from 2.98 to 2.03 (Likert scale) and trainees reported more senior support after hours (p=<0.05). More patients had documented advanced resuscitation planning following training 2.1 from 1.85 (Likert scale 1-4). Conclusion: It cannot be assumed that doctors have the core technical and non-technical skills required to confidently deliver high quality care. The MERT course is standardising and improving patient care.

‘They’ll inject you and you’ll die’: from medication non-compliance to acceptance in Guinea’s Ebola treatment units

During the 2013–2016 West African Ebola epidemic, medical emergency response teams negotiated a context marked by public hysteria and fear to prevent the spread of the virus and treat those already infected. However, the presence and work of Ebola response teams added to suspicions provoked by the rapid increase in numbers of dead and dying and by locally unintelligible emergency measures. Based on data collected from 40 young adult ‘survivors’ between 16 and 29 years of age who were hospitalized for Ebola during the epidemic, this article examines how pharmaceutical treatments were accepted (or not) by patients in ebola treatment units (ETU). Three key questions guide this analysis: (1) Did hospitalized individuals adhere with or refuse treatments offered at ETUs? (2) Did their attitudes change over the course of their hospitalization? (3) Which factors influenced refusal of treatment or compliance? To the authors’ knowledge, no previous studies have explored the resistance of hospitalized patients to treatment in Ebola centers. This article, in addition to exploring patients’ practices and related perceptions of treatment with evolving meanings in this outbreak crisis situation, also presents practical recommendations for future Ebola interventions as well as theoretical knowledge about the circulation and transformation of socially constructed representations of medications.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider.

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

BackgroundHypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of...

Working Memory Capacity and Surgical Performance While Exposed to Mild Hypoxic Hypoxemia.

Medical Emergency Response Team (MERT) helicopters fly at altitudes of 3000 m in Afghanistan (9843 ft). Civilian hospitals and disaster-relief surgical teams may have to operate at such altitudes or even higher. Mild hypoxia has been seen to affect the performance of novel tasks at flight levels as low as 5000 ft. Aeromedical teams frequently work in unpressurized environments; it is important to understand the implications of this mild hypoxia and investigate whether supplementary oxygen systems are required for some or all of the team members. Ten UK orthopedic surgeons were recruited and in a double blind randomized experimental protocol, were acutely exposed for 45 min to normobaric hypoxia [fraction of inspired oxygen (FIo2) ∼14.1%, equivalent to 3000 m (10,000 ft)] or normobaric normoxia (sea-level). Basic physiological parameters were recorded. Subjects completed validated tests of verbal working memory capacity (VWMC) and also applied an orthopedic external fixator (Hoffmann® 3, Stryker, UK) to a plastic tibia under test conditions. Significant hypoxia was induced with the reduction of FIo2 to ∼14.1% (Spo2 87% vs. 98%). No effect of hypoxia on VWMC was observed. The pin-divergence score (a measure of frame asymmetry) was significantly greater in hypoxic conditions (4.6 mm) compared to sea level (3.0 mm); there was no significant difference in the penetrance depth (16.9 vs. 17.2 mm). One hypoxic frame would have failed early. We believe that surgery at an altitude of 3000 m, when unacclimated individuals are acutely exposed to atmospheric hypoxia for 45 min, can likely take place without supplemental oxygen use but further work is required.Parker PJ, Manley AJ, Shand R, O'Hara JP, Mellor A. Working memory capacity and surgical performance while exposed to mild hypoxic hypoxemia. Aerosp Med Hum Perform. 2017; 88(10):918-923.

The modified ‘Jo'burg’ technique for securing intercostal chest drains

Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as...