Prehospital Medicine Research Articles

Crush Injury During Winter in the Backcountry: A Case Report


 Crush injuries are complicated and uncommon in prehospital medicine. They combine the complications of traumatic injuries, medical syndromes, and technical rescue. This conflagration of complex management issues can be very difficult for prehospital providers to control. Managing a crush injury in an austere environment adds a much higher degree of complication. In this article we present the case of an adult male who sustained a right leg injury when a boulder pinned his leg on a trail in Eldorado Springs Canyon, Colorado during a winter storm with subfreezing temperatures. Remote location and a harsh environment added to the complexity of this already difficult patient injury. A positive outcome was achieved by early recognition of the potential for crush syndrome by the treating medics, a coordinated lift operation with rescue crews, and a prompt field evacuation via litter.Cu

Responding to the COVID-19 pandemic: The experiences of South Australia's Rescue, Retrieval and Aviation Services.

COVID-19 poses significant challenges to pre-hospital and retrieval medicine (PHRM) clinicians - and many are unique to this area of clinical practice. We share the experiences of the South Australian Ambulance Service (SAAS) MedSTAR Emergency Medical Retrieval Service in preparing for the COVID-19 pandemic in the pre-hospital and retrieval setting - including the role of a multidisciplinary leadership team; challenges and potential approaches to screening for COVID-19; personal protective equipment for pre-hospital and aeromedical taskings; issues arising with interstate retrievals; and the role of telehealth. Although novel solutions allowed SAAS MedSTAR to continue to deliver high-quality care, considering the resource implications involved in undertaking the transfer of patients with COVID-19, it is clear that significant community disease transmission threatens to overwhelm any PHRM service. Should Australia face a significant future outbreak, it is conceivable that some PHRM operations may need to be reduced or suspended entirely.

Short Communication on Anesthesiology

Anesthesiology the medical specialty involved with the full perioperative care of patients before, throughout, and once surgery, it encompasses physiologicalstate, medical care drugs, vital medicine, and pain drugs. A Doctorspecialized during this field of medication is termed AN anesthesiologist. The core part of the specialty is that the study and use of physiological state and anesthetics to soundly support a patient's important functions through the perioperative amount. Since the nineteenth century, Anesthesiology has developed from an experimental space with non-specialist practitioner’s exploitation novel, untested medication, and techniques into what is currently an extremely refined, safe, and effective field of medication. In some countries anesthesiologists comprise the biggest single cohort of doctors in hospitals, and their role will extend so much on the far side the standard role of physiological state care within as well as fields like providing pre-hospital medicine, running medical care units, transporting critically unwell patients between facilities, and rehabilitation programs to optimize patients for surgery.

Rationale and Implementation of a Novel Special Operations Medical Officer Course.

The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Efficacy of Commercial Chest Seal Adherence and Tension Pneumothorax Prevention: A Systematic Review of Quantitative Studies.

Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces. A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation. Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study. While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.

First Aid UCV (Green Cross) for Prehospital Medicine in Social Commotion Situations.

Venezuela is living in a delicate social and political crisis that has taken thousands of lives. Beginning in March 2017, a series of continuous and increasingly violent demonstrations has taken place, with a high number of civilian casualties. These demonstrations typically have been outside the range of action of the government prehospital services. In addition, the number of casualties frequently overwhelmed the abilities of the available rescue services. Out of the need for a first aid team that could operate in this violent scenario, First Aid UCV (Central University of Venezuela) was created. A large number of professionals with medical, rescue, and tactical medicine experience integrated this new team, modifying their training and practice to adapt to a scenario in which unarmed medical students and medical doctors performed extractions, provided first aid, and managed the transport of demonstration casualties, doing so even when team members were sometimes targeted by the government police and military forces. This method has had successful results in all 60 operations conducted to date, with a total of 5,000 casualties being extracted among civilians, the military, and the police force. Only one member of the team was injured during the operations, and no deaths were reported during the process.

Out with the Old and in With the New: Deimplementation in Emergency Medicine.

Much of emergency medicine care and quality standards are rooted in evidence-based guidelines. The Society for Academic Emergency Medicine (SAEM) and the journal Academic Emergency Medicine through publications, conferences, and various initiatives have encouraged the emergency medicine community to create and disseminate evidence-based guidelines. New and updated guidelines must also be implemented into practice. Increasing numbers of publications in this journal and elsewhere are shining light on how the theories and frameworks of implementation science can increase the uptake, reach, and sustainability of evidence-based guidelines in emergency medicine.

Measurement of Tissue Oxygenation using Near-infrared Spectroscopy in Patients undergoing Hemodialysis.

Near-infrared spectroscopy (NIRS) has recently been applied as a tool to measure regional oxygen saturation (rSO2), a marker of tissue oxygenation, in clinical settings including cardiovascular and brain surgery, neonatal monitoring and prehospital medicine. The NIRS monitoring devices are real-time and noninvasive, and have mainly been used for evaluating cerebral oxygenation in critically ill patients during an operation or intensive care. Thus far, the use of NIRS monitoring in patients with chronic kidney disease (CKD) including hemodialysis (HD) has been limited; therefore, we investigated rSO2 values in some organs during HD. We monitored rSO2 values using a NIRS device transmitting near-infrared light at 2 wavelengths of attachment. The HD patients were placed in a supine position, with rSO2 measurement sensors attached to the foreheads, the right hypochondrium and the lower legs to evaluate rSO2 in the brain, liver and lower leg muscles, respectively. NIRS monitoring could be a new approach to clarify changes in organ oxygenation during HD or factors affecting tissue oxygenation in CKD patients. This article describes a protocol to measure tissue oxygenation represented by rSO2 as applied in HD patients.

Pre-hospital and retrieval medicine: Special skills placements and subspecialty training.

Pre-hospital and retrieval medicine: Special skills placements and subspecialty training.

Transition From Military Prehospital Medicine to Civilian EMS.

Currently, there is a disconnection between veteran military medics and the civilian Emergency Medical Services (EMS) workforce. This project aimed to characterize the rate of civilian certification among military medics, both active duty and retired, and identify perceived barriers to continuing a career in EMS after military separation. The National Association of Emergency Medical Technicians (EMTs) administered a 21-question online survey to participants. Individuals were recruited through the National Association of EMTs membership communications, Military Relations Committee members, and social media. All responses were anonymous and no identifiable information was collected. Survey questions were compiled and reported as a percentage of respondents. Free-text responses were categorized based on broad themes identified by the authors and are reported as a percentage of respondents. Results included 456 veteran and active duty respondents, of whom 304 (70.7%) had prehospital experience while in the military and 250 (58.1%) had emergency department experience. Over 60% of respondents participated in combat-related duty with 37% having at least 18months of overseas deployment. Civilian EMT certification was held by 164 (36.7%) survey participants and 170 held paramedic certification (38.1%), while 65 (14.6%) held no EMS certification. There were 119 (28.1%) respondents who stated that they did not plan to work in civilian EMS. Top selected reasons for not pursuing civilian EMS careers included: pursuing a medical career that was not prehospital (28.5%), pay disparity (18.1%), and no interest in civilian prehospital medicine (16.4%). Write in responses indicated general frustration with maintaining certification and a desire for advanced certification (AEMT, paramedic) to be supplied by the military prior to transitioning to a civilian workforce as many respondents felt their military-endowed skills and experiences were better aligned with these advanced EMS licenses. The majority of survey respondents held an EMS certification of some kind and suggests that recent efforts to supply military medics with civilian certifications have been largely successful. However, there is still a large portion that remains noncertified or expresses disinterest with entering the civilian workforce. Generally, many of those certified feel their military scope of practice exceeded civilian EMT certification and requested AEMT or paramedic licensure opportunities while still active duty military.

Zajištění dýchacích cest v přednemocniční péči dospělých - to tube or not to tube?

AdekvĂĄtnĂ­ zajiĹĄtěnĂ­ oxygenace a prĹŻchodnĂ˝ch dĂ˝chacĂ­ch cest je jednĂ­m z klíčovĂ˝ch faktorĹŻ pro přeĹžitĂ­ pacienta v přednemocničnĂ­ péči. HlavnĂ­m rozdĂ­lem proti operačnĂ­mu sĂĄlu je prostředĂ­ zĂĄsahu a zkuĹĄenost i kvalifikace zdravotnĂ­ka. ZĂĄkladnĂ­ techniky zahrnujĂ­ pouĹžitĂ­ manuĂĄlnĂ­ch manĂŠvrĹŻ ke zprĹŻchodněnĂ­ dĂ˝chacĂ­ch cest, ventilaci obličejovou maskou i zavedenĂ­ ĂşstnĂ­ch nebo nosnĂ­ch vzduchovodĹŻ. K pokročilĂ˝m technikĂĄm patří zavedenĂ­ supraglotickĂŠ pomĹŻcky a tracheĂĄlnĂ­ intubace. U malĂŠho mnoĹžstvĂ­ pacientĹŻ a ve vĂĄlečnĂŠ medicĂ­ně je nutnĂŠ pouŞít chirurgickou techniku zajiĹĄtěnĂ­ dĂ˝chacĂ­ch cest, koniotomii. TracheĂĄlnĂ­ intubace stĂĄle zĹŻstĂĄvĂĄ metodou volby v rukou zkuĹĄenĂŠho zdravotnĂ­ka pro stavy se zĂĄvaĹžnou poruchou vědomĂ­ a pro resuscitaci při zĂĄstavě oběhu. Pro zvýťenĂ­ Ăşspěšnosti tracheĂĄlnĂ­ intubace v terĂŠnu jsou pouŞívĂĄny dalĹĄĂ­ pomĹŻcky, buĹžie nebo videolaryngoskopy. SupraglotickĂŠ pomĹŻcky zavĂĄděnĂŠ v přednemocničnĂ­ péči zahrnujĂ­ laryngeĂĄlnĂ­ masky, i‑gel a laryngeĂĄlnĂ­ tubus.

Air ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review

BackgroundDedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments of pre-hospital and retrieval medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures to assess service performance. The objective of this scoping systematic review will be to identify and evaluate the range of air ambulance outcome measures reported in the literature and help to construct a quality dashboard based on a healthcare quality framework.MethodsWe will search PubMed, MEDLINE, CINAHL, Scopus, and Cochrane Database of Systematic Reviews (from January 2001 onwards). Complementary searches will be conducted in selected relevant journals. We will include systematic reviews and observational studies (cohort, cross-sectional, interrupted time series) in critically ill or injured patients published in English and focusing on air ambulance delivery and quality measures. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using appropriate tools. Analysis of the characteristics associated with outcome measure will be mapped and described according to the proposed healthcare quality framework.DiscussionThis review will contribute to the development of an air ambulance quality dashboard designed to combine multiple quality frameworks. Our findings will provide a basis for helping decision-making in health planning and policy.Systematic review registrationPROSPERO CRD42019144652

Drug and Alcohol Related Patient Presentations to Emergency Departments during Sporting Mass-Gathering Events: An Integrative Review.

Drug and alcohol consumption at sporting mass-gathering events (MGEs) has become part of the spectator culture in some countries. The direct and indirect effects of drug and alcohol intoxication at such MGEs has proven problematic to in-event health services as well as local emergency departments (EDs). With EDs already under significant strain from increasing patient presentations, resulting in access block, it is important to understand the impact of sporting and other MGEs on local health services to better inform future planning and provision of health care delivery. The aim of this review was to explore the impact of sporting MGEs on local health services with a particular focus on drug and alcohol related presentations. A well-established integrative literature review methodology was undertaken. Six electronic databases and the Prehospital and Disaster Medicine (PDM) journal were searched to identify primary articles related to the aim of the review. Articles were included if published in English, from January 2008 through July 2019, and focused on a sporting MGE, mass-gathering health, EDs, as well as drug and alcohol related presentations. Seven papers met the criteria for inclusion with eight individual sporting MGEs reported. The patient presentation rate (PPR) to in-event health services ranged from 0.18/1,000 at a rugby game to 41.9/1,000 at a recreational bicycle ride. The transport to hospital rate (TTHR) ranged from 0.02/1,000 to 19/1,000 at the same events. Drug and alcohol related presentations from sporting MGEs contributed up to 10% of ED presentations. Alcohol was a contributing factor in up to 25% of cases of ambulance transfers. Drug and alcohol intoxication has varying levels of impact on PPR, TTHR, and ED presentation numbers depending on the type of sporting MGE. More research is needed to understand if drug and alcohol intoxication alone influences PPR, TTHR, and ED presentations or if it is multifactorial. Inconsistent data collection and reporting methods make it challenging to compare different sporting MGEs and propose generalizations. It is imperative that future studies adopt more consistent methods and report drug and alcohol data to better inform resource allocation and care provision.

Fatigue in Aeromedicine: A Validity Study of the Flight Risk Assessment

ABSTRACT Objective: A validation study was conducted on the Flight Risk Assessment (FRA), a unique self-report fatigue measure for flight medics on duty. Background: Air medical professionals face unique challenges above and beyond the difficulty of working in a hospital setting or prehospital ground medicine. Providers frequently work multiple 24-hour shifts, resulting in circadian rhythm disturbance and cumulative sleep loss. The plane environment and the effects of flight are also contributory to fatigue; however, air medics must engage in emergent, time-sensitive, life-saving procedures despite these challenging circumstances. Although the aeromedical industry has rapidly expanded in the past several decades, the field of flight medicine lacks validated tools to evaluate fatigue levels, and many companies rely on flight providers’ recognition of fatigue to prevent work-related mistakes. Method: To establish construct validity, scores on the FRA were compared to scores on the Psychomotor Vigilance Test (PVT), an objective measure of fatigue. Results: The results indicate that a total of five questions on the FRA was significantly and strongly correlated with mean reaction time on the PVT (r = .60, p = .001). Perceived fitness for duty was poorly correlated with fatigue levels as measured by the FRA (r < .01) suggesting medics may have difficulty recognizing when they are fatigued and fit for duty. Conclusion: The air medical industry is rapidly expanding, and valid and reliable measures are indicated to assess fatigue levels among providers. Initial findings suggest the FRA is an efficient tool to objectively measure the fatigue levels of air medics through a self-report measure.

Microcirculation in Prehospital Medicine

Microcirculation in Prehospital Medicine

Implementing Wilderness Medicine Training for Undergraduate Medical Students in the UK

The UK General Medical Councils' approved curricula share only 3 topics with the Fellowship in the Academy of Wilderness Medicine core curriculum, suggesting an underrepresentation of wilderness medicine (WM) in medical education. We developed a 5-mo course to address the gaps between these curricula to run in parallel with the conventional curriculum. Our 71-h course is composed of lectures and practical exercises. We set out to evaluate the effectiveness of this concept and assess its suitability for use by other institutions. The course was undertaken by 18 medicine and healthcare undergraduates. Semiquantitative evaluation of the course was done using participants' self-reported WM knowledge and interest before and after the course using a Likert scale. Participants were further assessed with a WM objective structured clinical examination. Before the course, students had a lower understanding of WM (2.8/5.0) and were not confident in prehospital medicine (2.5/5.0). After the course, knowledge and confidence increased in all teaching categories, with a mean gain of 1.4/5.0 (P<0.05). Students demonstrated competence in a range of WM categories by completing the WM objective structured clinical examination, with a pass rate of 82%. Providing students with a WM course is effective in introducing components of the Fellowship in the Academy of Wilderness Medicine curriculum and inspiring future engagement in the field. We have developed a framework for successful implementation of WM teaching and shown that the concept may be used in other undergraduate settings.

Remote Ischemic Conditioning in Acute Myocardial Infarction – Implications of the CONDI-2/ERIC-PPCI Trial for Prehospital and Emergency Medicine

This commentary discusses the findings of the CONDI-2/ERIC-PPCI trial in the context of the existing literature on the topic, and the implications for prehospital and Emergency Medicine in terms of clinical practice and research relating to ischemic conditioning.

Articles That May Change Your Practice: Prone Position Ventilation

Acute respiratory distress syndrome (ARDS) in critically ill patients is a burden to health care worldwide because it carries a mortality rate of about 40%. In ARDS, diffuse and progressive inflammatory changes in the lung alveoli eventually lead to alveolar injury. This results in impaired gas exchange, leading to hypoxemia. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director at Ornge Transport Medicine; medical director at Toronto Paramedic Services; an associate professor in the Faculty of Medicine at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] Yuen Chin Leong, MD, MEmMed, is an emergency physician in Malaysia. He is currently pursuing the Emergency Medical Services Fellowship at Sunnybrook Center for Prehospital Medicine, University of Toronto, Canada.

Real-Time Impact Analysis and Response using a New Disaster Metrics: 2018 Sulawesi (Indonesia) Earthquake and Tsunami.

The Richter Scale measures the magnitude of the seismic activity for an earthquake; however, it does not quantify the humanitarian need at the point of impact. This poses a challenge for humanitarian stakeholders in decision and policy making, especially in risk reduction, response, recovery, and reconstruction. The new disaster metrics tool titled "The YEW Disaster Severity Index" (DSI) was developed and presented at the 2017 World Congress of Disaster and Emergency Medicine, May 2017, Toronto, Canada. It uses a median score of three for vulnerability and exposure indicators, a median score percentage of 100%, and medium YEW DSI scoring of four to five as baseline, indicating the ability to cope within local capacity. Therefore, scoring more than baseline coping capacity indicates that external assistance is needed. This special real-time report was presented at the 2nd National Pre-Hospital Care Conference and Championship, October 2018, Malaysia. The aim of this analysis is to present the real-time humanitarian impact and response to the 2018 earthquake and tsunami at Donggala and Palu, Sulawesi in Indonesia using the new disaster metrics YEW DSI. Based on the earthquake (measuring 7.7 on the Richter Scale) and tsunami at Donggala, the humanitarian impact calculated on September 29, 2018 scored 7.4 High in the YEW DSI with 11 of the total 17 indicators scoring more than the baseline coping capacity. The same YEW DSI score of 7.4 was scored on the earthquake and tsunami at Palu, with 13 of the total 17 indicators scoring more than baseline ability to cope within local capacity. Impact analysis reports were sent to relevant authorities on September 30, 2018. A State of Emergency was declared for a national response, which indicated an inability to cope within the local capacity, shown by the YEW DSI. The strong correlation between the earthquake magnitude, intensities, and the humanitarian impact at Donggala and Palu reported could be added into the science of knowledge in prehospital care and disaster medicine research and practice. As a conclusion, the real-time disaster response was found to be almost an exact fit with the YEW DSI indicators, demonstrating the inability to cope within the local capacity.

Decision making in prehospital traumatic cardiac arrest; A qualitative study

BackgroundDespite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. MethodsTwenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. ResultsEight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. ConclusionEight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines.