Prehospital Emergency Medicine Research Articles

Development of a novel global rating scale for objective structured assessment of technical skills in an emergency medical simulation training

BackgroundMedical simulation trainings lead to an improvement in patient care by increasing technical and non-technical skills, procedural confidence and medical knowledge. For structured simulation-based trainings, objective assessment tools are needed to evaluate the performance during simulation and the learning progress. In surgical education, objective structured assessment of technical skills (OSATS) are widely used and validated. However, in emergency medicine and anesthesia there is a lack of validated assessment tools for technical skills. Thus, the aim of the present study was to develop and validate a novel Global Rating Scale (GRS) for emergency medical simulation trainings.MethodsFollowing the development of the GRS, 12 teams of different experience in emergency medicine (4th year medical students, paramedics, emergency physicians) were involved in a pre-hospital emergency medicine simulation scenario and assessed by four independent raters. Subsequently, interrater reliability and construct validity of the GRS were analyzed. Moreover, the results of the GRS were cross-checked with a task specific check list. Data are presented as median (minimum; maximum).ResultsThe GRS consists of ten items each scored on a 5-point Likert scale yielding a maximum of 50 points. The median score achieved by novice teams was 22.75 points (17;30), while experts scored 39.00 points (32;47). The GRS overall scores significantly discriminated between student-guided teams and expert teams of emergency physicians (p = 0.005). Interrater reliability for the GRS was high with a Kendall’s coefficient of concordance W ranging from 0.64 to 0.90 in 9 of 10 items and 0.88 in the overall score.ConclusionThe GRS represents a promising novel tool to objectively assess technical skills in simulation training with high construct validity and interrater reliability in this pilot study.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

BackgroundThe number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.MethodsThis analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).Results53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21–3.30; OROFF 3.18, 95% CI 3.04–3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9–47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6–79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.ConclusionsThis study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project

IntroductionAdvanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway...

Consensus on research priorities for Essex & Herts Air Ambulance: a Delphi study

BackgroundConsensus methods such as the Delphi technique have been used widely for research priority setting in health care. Within pre-hospital emergency medicine, such approaches have helped to establish national and international research priorities. However, in a dynamic field such as pre-hospital critical care, it is necessary to regularly review the continued relevance of findings. Further, considering the variability between pre-hospital critical care providers, it is also important to determine priorities at the local level. Essex & Herts Air Ambulance (EHAAT) sought to develop a five-year research strategy that aligns with their clinical work streams and organisational priorities.MethodsAll staff and Trustees were invited to participate in an online Delphi study with three Rounds. The Delphi was administered via email and Online Surveys software. The first Round invited participants to submit up to five research questions that they felt were of greatest importance to EHAAT to advance the care provided to patients. In Round 2, participants were asked to rate the importance of questions from Round 1, while Round 3 required participants to rank questions that were prioritised in Round 2 in order of importance.Results22 participants submitted a total of 86 research questions in Round 1, which were reduced to 69 questions following deduplication and refinement. 11 participants rated the importance of the questions in Round 2, resulting in 14 questions being taken forward to Round 3. Following the ranking exercise in Round 3, completed by 12 participants, a top five research priorities were identified. The question deemed most important was “How does a pre-hospital doctor-paramedic team affect the outcome of patients with severe head injuries?”.ConclusionsThe top five research priorities identified through the Delphi process will inform EHAAT’s research strategy. Findings suggest that there is still work to be done in addressing research priorities described in previous literature.

Initial Prehospital Rapid Emergency Medicine Score (REMS) as a Predictor of Patient Outcomes

Background: A standardized objective measure of prehospital patient risk of hospitalization or death is needed. The Rapid Emergency Medicine Score (REMS), a validated risk-stratification tool, has not been widely tested for prehospital use. This study’s objective was to assess predictive characteristics of initial prehospital REMS for ED disposition and overall patient mortality. Methods: This retrospective analysis used linked prehospital and hospital data from the national ESO Data Collaborative. All 911 responses from 1/1/2019–12/31/2019 were included. REMS (0–26) was calculated using age and first prehospital values for: pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale. Non-transports, patients <18 and cardiac arrests prior to EMS arrival were excluded. The primary outcome was ED disposition, dichotomized to discharge versus admission, transfer, or death. The secondary outcome was overall survival to discharge (ED or inpatient). Transfers and records without inpatient disposition were excluded from the secondary analysis. Predictive ability was assessed using area under the receiver operating curve (AUROC). Optimal REMS cut points were determined using test characteristic curves. Univariable logistic regression modeling was used to quantify the association between initial prehospital REMS and each outcome. Results: Of 579,505 eligible records, 94,640 (16%) were excluded due to missing data needed to calculate REMS. Overall, 62% (n = 298,223) of patients were discharged from the ED, 36% (n = 175,212) were admitted, 2% (n = 10,499) were transferred, and 0.2% (n = 931) died in the ED. A REMS of 5 or lower demonstrated optimal statistical prediction for ED discharge versus not discharged (admission/transfer/death) (AUROC: 0.68). Patients with initial prehospital REMS of 5 or lower showed a three-fold increase in odds of ED discharge (OR: 3.28, 95%CI: 3.24–3.32). Of the 457,226 patients included in overall mortality analysis, >98% (n = 450,112) survived. AUROC of initial prehospital REMS for overall mortality was 0.79. A score 7 or lower was statistically optimal for predicting survival. Initial prehospital REMS of 7 or lower was associated with a five-fold increase in odds of overall survival (OR:5.41, 95%CI:5.15–5.69). Conclusion: Initial prehospital REMS was predictive of ED disposition and overall patient mortality, suggesting value as a risk-stratification measure for EMS agencies, systems and researchers.

Point-of-care testing as the future of pre-hospital emergency medicine: an overview

Point-of-care testing (POCT) plays an increasingly important role in pre-emergency medicine by ensuring that patient’s continuum of care is commenced before arrival at health facilities. Given the benefits of POCT during the COVID-19 pandemic, this commentary described the advantages and disadvantages of POCT, and its current practices in pre-hospital emergency medicine. Point-of-care tests are easy to operate, cost-effective, and yield quick and accurate response, but are posed with challenges such as safety errors, poor adherence to quality control standards, and inspection errors. To optimize the benefits of POCT in pre-emergency medicine, it is required that regular trainings are conducted for POCT operators, and total compliance to POCT handling and management guidelines should be considered by each POCT operator.

Herding cats: ethics in prehospital triage

Objective: Triage can create an ethical slippery slope when providing prehospital emergency health care. In triage decisions, emergency management is like the idiom of “herding cats”, which refers to managing or controlling the chaos and organizing people toward common goals. The purpose of this literature review is to explore the ethical framework of prehospital triage and to provide a critical view of the subject. Methods: Published materials related to “triage”, “ethics”, and “prehospital emergency medicine” were extracted from online databases and books from 1985 until February 2021. The papers were handled in seven themes including the historical basis, the importance of the triage, ethical considerations in prehospital triage, justice, assessment and decision-making, the variability of triage assessment criteria, and the reliability of triage decisions. Except for the historical basis and the importance of triage, the other five groups were discussed with an ethical critique of the content. The methodology in this article is based on a critical interpretation of discussions on triage through ethical approaches. Results: There are three basic ethical approaches to triage: utilitarianism, beneficence, and justice. Due to the historical military basis of triage, results-focused approaches have become more prominent. Ethical values in prehospital triage include the issues of human rights, moral rights, social justice, and beneficence. Ethical difficulties in triage decision-making involve vulnerability, limited resources, the concern of safety, the urgency of the situation, and instability. Triage decisions may be affected by subjective approaches such as the personal values and beliefs of the decision-makers. Conclusions: Three predominant ethical concepts in triage are utilitarianism, beneficence, and justice. The unique dynamics of the field influence triage decision-making in a variety of ways. The way triage is structured makes it more amenable to subjective influences. Considering the differences in prehospital triage models and approaches, there is an important need for an ethical framework that expresses clear values and principles that will guide prehospital emergency caregivers. In this paper, it is suggested that an ethical framework should include the following six headings: basic bioethical principles, distributing scarce resources, decision-making process, community support, assessment criteria, and promote the common good.

Evaluation of a Prehospital Rotation by Senior Residents: A Web-Based Survey

The added value of prehospital emergency medicine is usually assessed by measuring patient-centered outcomes. Prehospital rotations might however also help senior residents acquire specific skills and knowledge. To assess the perceived added value of the prehospital rotation in comparison with other rotations, we analyzed web-based questionnaires sent between September 2011 and August 2020 to senior residents who had just completed a prehospital rotation. The primary outcome was the perceived benefit of the prehospital rotation in comparison with other rotations regarding technical and non-technical skills. Secondary outcomes included resident satisfaction regarding the prehospital rotation and regarding supervision. A pre-specified subgroup analysis was performed to search for differences according to the participants’ service of origin (anesthesiology, emergency medicine, or internal medicine). The completion rate was of 71.5% (113/158), and 91 surveys were analyzed. Most senior residents found the prehospital rotation either more beneficial or much more beneficial than other rotations regarding the acquisition of technical and non-technical skills. Anesthesiology residents reported less benefits than other residents regarding pharmacological knowledge acquisition and confidence as to their ability to manage emergency situations. Simulation studies should now be carried out to confirm these findings.

Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison

Background: There is limited research outside the USA, Europe, or Australia on the capacity, efficiency, and development of prehospital emergency medicine services (EMS) between urban and rural areas. This study aimed to examine the usage of prehospital EMS across rural and urban areas in Riyadh region in the Kingdom of Saudi Arabia. Methods: A random sample of 800 (400 urban and 400 rural) emergency patient records from the Saudi Red Crescent Authority EMS was collected. The following variables were analyzed: patient demographics, clinical characteristics, length of hospital stay, and length of intensive care unit (ICU) stay. Results: A skewed distribution was noted with respect to sex, i.e., 559 men versus 241 women. Rural patients were younger (42.75 vs. 39.72 years) and had significantly longer hospital (15 days versus 9 days) and ICU (5 days versus 2 days) stays than urban patients following transportation. All injury types were comparable, except for head injury, which was higher in the rural group than in the urban group. Advanced treatment and trauma transport were more often used in rural areas than in urban areas. Conclusions: In this study, rural EMS users were more likely to experience trauma-related incidents that necessitate EMS transportation, while medical reasons were more common among urban EMS users. Moreover, men used EMS at much higher rates than women and were more likely to be transported to the hospital following a call-out.

FAMILY PRESENCE AND THE PRESS EFFECTS ON PREHOSPITAL CARDIOPULMONARY RESUSCITATION: ATTITUDES OF A GROUP OF EMERGENCY CAREGIVERS

There have been many studies regarding family presence during cardiopulmonary resuscitation and most of them are about emergency services or intensive care units. However, the issue has not been studied enough in terms of prehospital emergency medicine and the perspective of prehospital emergency caregivers. In this study, it is aimed to present the attitudes of a group of prehospital emergency care professionals to family presence and the press effects during prehospital cardiopulmonary resuscitation. The data for this descriptive research was collected from the participants of 63 prehospital caregivers in Afyonkarahisar. The data was collected using a questionnaire designed by the authors and the responses summarized by using frequencies and percentages. Descriptive statistics were used to characterize the sample and each of the survey items. The local ethics committee approval was obtained. Most participants were strongly opposed to family presence and the press during CPR. The highest mean in the phrases that “I don’t want any press member to be there when I perform CPR on a patient.” There is no significant difference in family presence during CPR between the role and year of the experience. Prehospital emergency caregivers mostly have negative attitude towards family presence and the press during CPR. They mostly think the presence of significant others and being watched adversely affects their CPR performance. Disturbing effect on caregivers is not only related to the presence of family members or to other significant others but also the press. Family presence and the press effect on prehospital cardiopulmonary resuscitation are crucial issues that need more attention.

The Tele-Emergency Physician System as an Innovation in the Emergency Medical Service: Evaluation of Potentials by Employees of German Ambulance Control Centres

One of the health policy challenges lies in guaranteeing comprehensive emergency care in Germany. Telemedical applications are assumed to be a potential solution to current problems. One of these innovations is the tele-emergency physician system, which changes the workflows of the various actors in prehospital emergency medicine. The aim of the study was to determine how the potentials of the tele-emergency physician system were evaluated by employees of the ambulance control centres in Germany. In the cross-sectional study, employees of ambulance control centres throughout Germany were interviewed using an online-based questionnaire. The results are illustrated in a sub-group analysis according to the state of knowledge on innovation, either (very) low or (very) high. Correlation analyses were carried out to determine significant differences between the subgroups. Data analysis was performed using Microsoft Excel 2013 and IBM SPSS Version 25. The response rate was 69.04%. Of those surveyed, 76.23% expected that the tele-emergency physician system would save them a relevant amount of time. 57.38% believed that patients would be transported faster and 51.64% of the respondents did not see any chance of cost savings in the health care system. Significant evaluation differences resulted in expected time saving (p=0.004), shorter time to transport (p=0.009) and cost saving (p=0.0004). 64.71% thought that there would be a risk of increased documentation effort. 56.41% did not believe that patients would be sufficiently informed about the legal provisions on data protection during their tele-emergency physician treatment. The increase in documentation effort (p=0.02) and patients being sufficiently informed about data protection regulations (p=0.015) were evaluated significantly differently. 90.98% of the respondents rated the tele-emergency physician system as meaningful. The rural region was considered by 47.62% of the respondents as the primary region where the use of system would be necessary. 36.29% of the participants stated that a tele-emergency physician system should be implemented in their own area. All in all, the tele-emergency physician system is considered useful in prehospital emergency medical service by the staff of the emergency control centres. However, the majority of participants do not assume that there is potential for implementation of this system in their own region.

Care time Delays in Acute Coronary Syndromes with Persistent St Elevation (stem) and the Delaying Factors: Prospective STUDY About 50 Cases in the Cardiology Department of Aristide le Dante Hospital.

The care of acute coronary syndrome with persistent ST-elevation (STEMI) is a time-trial race: ‘‘time is myocardium”. The treatment relies on myocardial reperfusion by percutaneous coronary intervention (PCI) or fibrinolysis as promptly as possible. The main objective of this work was to assess the care time delays and the delaying factors during STEMI. We conducted a prospective, descriptive and analytic study over a 6 months’ time period. Were included all the patients received for STEMI. We have studied the care time delays and the delaying factors. We have compiled 50 patients. The mean age was 58.4 years and the sex-ratio M/F 2.5. The chest pain was typical in 39 patients. The mean time elapsed between the beginning of the pain and the first medical contact was 12 h 16 min. Transport (76%) and self-medication (70%) were the significant delaying factors found (p = 0.0001). The mean time elapsed between the first medical contact and the electrocardiogram was 9 h 57 min. The main factors delaying the diagnosis were the unavailability of the electrocardiogram device and the absence of electrocardiogram prescription (p = 0.001). The mean time elapsed between the electrocardiogram and the admission in the cardiology department was 3 h 02 min. The transport was the principal factor lengthening that time delay (p = 0.0001). Among the patients admitted directly in cardiology department, the mean time delay to perform the ECG was 30 min. The mean time delay of fibrinolysis was 2 h 11 min. Streptokinase shortage was the most frequent delaying factor (p = 0.001). The mean time delay between the qualifying ECG and the PCI completion was 2 h 42 min. The unavailability of the medical team was the first factor lengthening that time delay (p = 0.0001). The care time delays were lengthened enough in our context. This testifies to the lack of a codified strategy for STEMI care. It is essential to develop pre-hospital emergency medicine and sensitize the population and healthcare professionals.

‘Going into the unknown isn’t something that scares me’

Pre-hospital emergency medicine consultant nurse Andy Thurgood on his challenging role

Rescue Blankets-Transmission and Reflectivity of Electromagnetic Radiation

Rescue blankets are medical devices made of a polyethylene terephthalate sheet coated with a thin aluminum layer. Blankets are used for protection against hypothermia in prehospital emergency medicine and outdoor sports, but totally different qualities are typical for these multi-functional tools. On the one hand, rescue sheets prevent hypothermia by reducing thermo-convection and diminishing heat loss from evaporation and thermal radiation. On the other hand, the sheets promote cooling by acting as a radiant barrier, by providing shade and even by increasing heat conduction when the sheet is in direct contact with the skin. As foils are watertight and windproof, they can function as vapor barriers and even as stopgap bivouac sacks. We evaluated three experimental studies, one on heat loss by rescue blankets according to surface color, one on transparency with ultraviolet radiation, high-energy visible light and visible light, and one on infrared radiation from rescue blankets. When evaluating the effects of different bands of the electromagnetic spectrum on rescue sheets, we focused on ultraviolet radiation (200–380 nm), high-energy visible light in the violet/blue band (380–450 nm), visible light (380–760 nm) and infrared radiation (7500–13,500 nm). Rescue sheets transmit between 1% and 8% of visible light and about 1% of ultraviolet B radiation (280–315 nm), providing sufficient transparency and adequate protection from snow blindness. Reflection of visible light increases detectability in search and rescue missions performed in good visibility conditions, while reflection of infrared radiation increases detectability in poor visibility conditions and provides protection against hypothermia.

Approaches to atrial fibrillation with tachycardia transition

Atrial fibrillation, the most common cardiac arrhythmia in the daily clinical routine, is achallenge in in-hospital and prehospital emergency medicine and is associated with increased morbidity and mortality if left untreated. Especially tachyarrhythmia, caused by atrial fibrillation, leads to various unspecified symptoms and in some cases to severely impaired circulation. Thus, an individualized therapeutic regimen is required. A fundamental distinction between rhythm control and rate control strategies must be made. In symptomatic but hemodynamically stable patients rate control is the method of choice. This applies in particular to patients with no pre-existing anticoagulation, especially if left atrial thrombi are not excluded. In hemodynamically unstable patients, considering the potential complications of sedation, electrical cardioversion is preferred. Pharmacological therapy of atrial fibrillation has to be divided into AV conduction modulating drugs-like short- or long-acting β‑blockers, calcium antagonists or cardiac glycosides-and the heterogeneous group of antiarrhythmic drugs aiming for rhythm control. Pulmonary vein ablation is the current long-term treatment of choice for symptomatic drug-refractory atrial fibrillation.

Delays in the management of acute coronary syndroms with ST segment elevation and extending factors: Prospective study about 50 cases in cardiology department of Aristide Le Dantec hospital.

Management of acute coronary syndromes with ST segment elevation (STEMI) is a race again time: time is myocardium». Treatment consist in reperfusion strategy by coronary intervention or thrombolysis. The main objective of this work was to evaluate the time delays of treatment and the extending factors during STEMI. It was a prospective, descriptive and analytic study on 6 months including all patients admitted for STEMI. We studied the time delays and the extending factors. We included 50 patients. The average age was 58,4 years and the sex ratio M/F was 2,5. Chest pain was typical for 39 patients. Mean time delay between pain onset and first medical contact was 12 h16 min. The first medical contact was a general physician for 33 patients and a cardiologist for 8 patients. The average time delay between the first medical contact and an electrocardiogram was 9 h57 min. The main factor of late diagnosis were unavailability of electrocardiograph and absence of prescription of an electrocardiogram. The average time delay between the diagnosis electrocardiogram and admission in cardiology department was 3 h02 min. The transport was the main extending factor. Aspirin and clopidogrel were used respectively for 17 and 10 patients. Among the patients admitted directly in cardiology, the average time delay for a diagnostic electrocardiogram was 30 min. Thrombolysis was performed in 17 patients within an average delay of 2 h11 min. A rupture of streptokinase was the most common extending factor. Twenty-three patients underwent percutaneous coronary intervention with a main time delay between diagnostic electrocardiogram and cath lab of 2 h42 min. The unavailability of medical team was the first extending factor. Factors related to long delay in admission and care are a proof of lack of codified management of STEMI. It is necessary to develop the prehospital emergency medicine, educate population and medical staff.

Implementation Strategy and Systemic Effects of Routine Telemedical Care in Prehospital Emergency Medicine

Implementation Strategy and Systemic Effects of Routine Telemedical Care in Prehospital Emergency Medicine

Developing a Model for the Establishment of Pre-Hospital Emergency Medicine Bases in the Northern Provinces of Iran

BACKGROUND: The faster and more accurately Pre-Hospital Emergency Medicine as the first line of care and treatment is done, the less the mortality and disability rates are.AIM: The present study is an attempt to design a model for the establishment of pre-hospital emergency bases in the northern provinces of Iran.METHODS: This quantitative-qualitative (mixed-method) research was conducted in two parts: First, using the literature review, interviews with experts in the field, and a comparative study, the most important factors affecting the establishment were extracted. Second, the obtained data were employed to formulate the development model and to design the questionnaire. The required data for factor analysis were collected through a questionnaire distributed among 200 operational personnel in January 2018. The results were analyzed using confirmatory factor analysis and multiple regression.RESULTS: Five components were identified after the exploratory factor analysis and Varimax with an eigenvalue larger than 1. The effect coefficients calculated for human resources components, service speed, and information and communication system were 0.935, 0.765 and 0.752, respectively. The obtained goodness of fit was very close to one, indicating the one-dimensional strength of the model. The highest parameter estimation in this model was allocated to the human component as 0.935, which has a significant correlation with other components.CONCLUSIONS: In order to reduce the response time, more attention should be paid to the allocation of budget and organizational roles, education, participation from government departments, establishment of an independent medical emergency organization, and appropriate accessibility to reduce the rates of mortality and morbidity.

Single mission workload and influencing factors in German prehospital emergency medicine - a nationwide prospective survey of 1361emergency missions

BackgroundWorkload is a major determinant of system performance and human well-being. This study aims to evaluate workload in prehospital emergency medicine on a single mission level and investigates influencing factors originating from medical scenarios, patient-provider interaction, EMS logistics and teamwork.MethodsIn a nationwide study, German paramedics were asked to evaluate single missions for perceived workload by completing the NASA Task-Load-Index (TLX). A variety of candidate variables were documented and tested for influence on the TLX through multivariate regression analysis.ResultsOne thousand three hundred sixty-one emergency missions were analysed. Global workload scored in medium ranges (Median TLX 41.00/100; IQR 24.25–57.50). 263 missions achieved very low (< 20/100) and 52 missions achieved very high (> 80/100) levels of workload. Severity of distress as indicated by the NACA score (delta TLX 2.71 per 1 NACA point), execution of invasive procedures (e.g. delta TLX 8.20 for intravenous access), obese patients (delta TLX 0.05 per 1 kg of weight) and aggression incidences (e.g. delta TLX 10.54 for physical aggression), amongst others, resulted in significant increases in workload. Good teamwork decreased workload by 2.18 points per 1 point on the Weller-Teamwork Measurement Tool.ConclusionDistinct factors result in significant increases in workload for EMS paramedics. Improvements in training for certain medical scenarios, strategies against aggression events and enhancements in EMS logistics - especially for the transfer of obese patients – should be implemented and tested for their presumably positive effect on workload, EMS performance and paramedics’ well-being.

Accuracy of low-weight versus standard syringe infusion pump devices depending on altitude

BackgroundIntravenous drug infusions in critically ill patients require accurate syringe infusion pumps (SIPs). This is particularly important during transportation of critically ill patients by helicopter emergency medical services (HEMS), where altitude may influence device performance. Because weight is a real concern in HEMS, new low-weight devices are very appealing.The aim of this study was to compare infusion flow rates delivered by low-weight versus standard SIP devices, in the prehospital emergency medicine setting, at different altitudes.MethodsWe conducted a comparative bench study involving five SIP devices (two standard and three low-weight models) at 300, 1700 and 3000 m altitude. The primary endpoint was the flow rate delivered by SIPs for prespecified values. We used two methods to measure flow. The normative method consisted in measuring weight (method A) and the alternate method consisted in measuring instantaneous flow (method B).ResultsUsing method A, no significant differences were found in median flow rates and interquartile range depending on device and altitude for a prespecified 10-mL/h flow. However, method B showed that low-weight SIPs delivered multiple sequential boluses with substantial variations (1.2–15.8 mL/h) rather than a prespecified continuous 5-mL/h flow. At 1700 m altitude, the interquartile range of delivered flows increased only for low-weight devices (p for interaction< 0.001).ConclusionsDespite satisfactory normative tests, low-weight SIPs deliver discontinuous flow with potential clinical implications for critically ill patients receiving vasoactive drugs. This study also highlights a thus far unknown negative impact of altitude on SIP function. We believe that normative requirements for SIP approval should be revised accordingly.