Prehospital Emergency Physicians Research Articles

Qualification requirements for prehospital emergency physicians are too low: we need a higher uniform standard!

Qualification requirements for prehospital emergency physicians are too low: we need a higher uniform standard!

Analysis of adifferentiated resuscitation room activation at anational trauma center

In order to continue to efficiently provide both personnel-intensive and resource-intensive care to severely injured patients, some hospitals have introduced individually differentiated systems for resuscitation room treatment. The aim of this study was to evaluate the concept of the A and B classifications in terms of practicability, indications, and potential complications at anational trauma center in Bavaria. In aretrospective study, data from resuscitation room trauma patients in the year 2020 were collected. The assignment toA andB was made by the prehospital emergency physician. Parameters such as the injury severity score (ISS), Glasgow outcome scale (GOS), upgrade rate, and the indication criteria according to the S3guidelines were recorded. Statistical data comparisons were made using t‑tests, χ2-tests, or Mann-Whitney U‑tests. Atotal of 879 resuscitation room treatments (A 473, B 406) met the inclusion criteria. It was found that 94.5% of resuscitation roomA cases had physician accompaniment, compared to 48% in resuscitation roomB assignments. In addition to significantly lower ISS scores (4.1vs. 13.9), 29.8% of Bpatients did not meet the treatment criteria defined in the S3guidelines. With alow upgrade rate of 4.9%, 98% of B patients had aGOS score of4 or5. The presented categorization is an effective and safe way to manage the increasing number of resuscitation room alerts in aresource-optimized manner.

Development and usability testing of a fully immersive VR simulation for REBOA training

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training.MethodsProspective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed.ResultsREBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3–85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8–5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8–50.2) and user satisfaction high (USEQ median 26, IQR 23–29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001).ConclusionsProcedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning.

Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey

BackgroundPrehospital care of psychiatric patients often relies on the medical experience of prehospital emergency physicians (PHEPs). The psychiatrists (PSs) involved in the further treatment of psychiatric patients also often rely on their experience. Furthermore, the interaction between PHEPs and PSs is characterized by interaction problems and different approaches in the prehospital care of the psychiatric emergency.ObjectivesTo analyze the phenomenon of “medical experience” as a cause of possible interaction-related problems and assess its impact on the prehospital decision-making process between prehospital emergency physicians and psychiatrists.MethodsThe retrospective data analysis was conducted between November 2022 and March 2023. Medical experience was defined as follows, based on the demographic information collected in the questionnaires: For PHEPs, the period since obtaining the additional qualification in emergency medicine was defined as a surrogate marker of medical experience: (i) inexperienced: < 1 year, (ii) experienced: 1–5 years, (iii) very experienced: > 5 years. For PSs, age in years was used as a surrogate parameter of medical experience: (i) inexperienced: 25–35 years, (ii) experienced: 35–45 years, (iii) very experienced: > 45 years.ResultsInexperienced PSs most frequently expressed anxiety about the psychiatric emergency referred by a PHEP (27.9%). Experienced PHEPs most frequently reported a lack of qualifications in handling the care of psychiatric emergencies (p = 0.002). Very experienced PHEPs were significantly more likely to have a referral refused by the acute psychiatric hospital if an inexperienced PS was on duty (p = 0.01). Experienced PHEPs apply an intravenous hypnotic significantly more often (almost 15%) than PSs of all experience levels (p = 0.001). In addition, very experienced PHEPs sought prehospital phone contact with acute psychiatry significantly more often (p = 0.01).ConclusionPHEPs should be aware that the PS on duty may be inexperienced and that treating emergency patients may cause him/her anxiety. On the other hand, PHEPs should be receptive to feedback from PS who have identified a qualification deficiency in them. Jointly developed, individualized emergency plans could lead to better prehospital care for psychiatric emergency patients. Further training in the prehospital management of psychiatric disorders is needed to minimize the existing skills gap among PHEPs in the management of psychiatric disorders.

Prehospital postcardiac-arrest-sedation and -care in the Federal Republic of Germany-aweb-based survey of emergency physicians

This study evaluates the implementation of postcardiac-arrest-sedation (PCAS) and -care (PRC) by prehospital emergency physicians in Germany. Analysis of aweb-based survey from October to November2022. Questions were asked about implementation, medications used, complications, motivation for implementing or not implementing PCAS, and measures and target parameters of PRC. Atotal of 500 emergency physicians participated in the survey. In all, 73.4% stated that they regularly performed PCAS (hypnotics: 84.7%; analgesics: 71.1%; relaxants: 29.7%). Indications were pressing against the respirator (88.3%), analgesia (74.1%), synchronization to respirator (59.5%), and change of airway device (52.6%). Reasons for not performing PCAS (26.6%) included unconscious patients (73.7%); concern about hypotension (31.6%), re-arrest (26.3%), and worsening neurological assessment (22.5%). Complications of PCAS were observed by 19.3% of participants (acute hypotension [74.6%]); (re-arrest [32.4%]). In addition to baseline monitoring, PRC included 12-lead-electrocardiogram (96.6%); capnography (91.6%); catecholamine therapy (77.6%); focused echocardiography (20.6%), lung ultrasound (12.0%) and abdominal ultrasound (5.6%); induction of hypothermia (13.6%) and blood gas analysis (7.4%). An etCO2 of 35-45 mm Hg was targeted by 40.6%, while 9.0% of participants targeted an SpO2 of 94-98% and 19.2% of participants targeted asystolic blood pressure of ≥ 100 mm Hg. Prehospital PRC in Germany is heterogeneous and deviations from its target parameters are frequent. PCAS is frequent and associated with relevant complications. The development of preclinical care algorithms for PCAS and PRC within preclinical care seems urgently needed.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study.

Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Assessment of Gender Bias During Paramedic-Physician Handoffs.

Objective Gender bias against female physicians has been frequently demonstrated and associated with negative feelings toward their careers. Gender bias has also been demonstrated in prehospital clinical care. However, potential gender bias during paramedic-physician handoffs has not been studied. This study aimed to identify gender bias during interactions between prehospital personnel and emergency physicians at the time of patient handoff. Methods An observational study was conducted at an urban academic emergency department. Observers were trained to record information from paramedic-physician handoffs but were blind to the nature of the study. The primary outcome was to whom paramedics initially directed the focus of their handoff report based on physician gender, with secondary outcomes of to whom paramedics directed most of their report and whether they asked about further questions based on physician gender. Results There were 784 observed handoffs. There was no significant association between the gender of the physician and which physician received first attention (χ2{1, N = 782} = 0.9736, p = 0.3238) or majority attention (χ2{1, N = 780} = 1.9414, p = 0.1635). Paramedics were more likely to ask questions to male attendings than female attendings (χ2 {1, N = 784} = 4.4319, p = 0.0353). Conclusion We identified limited differences in communication based on gender between paramedics and physicians during emergency department patient handoffs.

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study.

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting. The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP. This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected. PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions. This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Second Victims among German Emergency Medical Services Physicians (SeViD-III-Study)

Patient care in the prehospital emergency setting is error-prone. Wu's publications on the second victim syndrome made very clear that medical errors may lead to severe emotional injury on the caregiver's part. So far, little is known about the extent of the problem within the field of prehospital emergency care. Our study aimed at identifying the prevalence of the Second Victim Phenomenon among Emergency Medical Services (EMS) physicians in Germany. Web-based distribution of the SeViD questionnaire among n = 12.000 members of the German Prehospital Emergency Physician Association (BAND) to assess general experience, symptoms and support strategies associated with the Second Victim Phenomenon. In total, 401 participants fully completed the survey, 69.1% were male and the majority (91.2%) were board-certified in prehospital emergency medicine. The median length of experience in this field of medicine was 11 years. Out of 401 participants, 213 (53.1%) had experienced at least one second victim incident. Self-perceived time to full recovery was up to one month according to 57.7% (123) and more than one month to 31.0% (66) of the participants. A total of 11.3% (24) had not fully recovered by the time of the survey. Overall, 12-month prevalence was 13.7% (55/401). The COVID-19 pandemic had little effect on SVP prevalence within this specific sample. Our data indicate that the Second Victim Phenomenon is very frequent among prehospital emergency physicians in Germany. However, four out of ten caregivers affected did not seek or receive any assistance in coping with this stressful situation. One out of nine respondents had not yet fully recovered by the time of the survey. Effective support networks, e.g., easy access to psychological and legal counseling as well as the opportunity to discuss ethical issues, are urgently required in order to prevent employees from further harm, to keep healthcare professionals from leaving this field of medical care and to maintain a high level of system safety and well-being of subsequent patients.

Participation of pre-hospital emergency physicians at ambulance missions in Germany's federal states

PurposeThis study aims to determine the differences in the involvement of pre-hospital emergency physicians (PHEPs) within the ambulance service over time and between the federal states and identify possible reasons for the differences.Design/methodology/approachThe federal state-specific PHEP rates from 2012 to 2017 were analysed using publicly available data or data provided by the responsible state ministries. In addition, various correlations between PHEP rates and sociodemographic and health data were calculated.FindingsThe PHEP rates differ significantly between the 16 federal states. In 2017, Schleswig–Holstein had a PHEP participation rate of 19.00%, while in Mecklenburg-Western Pomerania the rate was 41.08%. In all surveyed states, the rate fell over time. Only in Mecklenburg-Western Pomerania, the rate increased from 37.68% in 2012 to 41.08% in 2017 (OR: 1.15 [95% CI: 1.14; 1.17]). Federal state-specific PHEP rates indicated strong deviations from the overall PHEP rate of all included federal states with ORs ranging from 0.61 (95% CI: 0,61; 0,62) for Schleswig–Holstein to 1.82 (95% CI: 1.81; 1.84) for Mecklenburg-Western Pomerania. Socioeconomic factors indicated (inverse) correlations with the federal state-specific PHEP rate.Originality/valueThe PHEP rates differ significantly between the federal states. The correlations indicate possible connections but do not show clear causes within state-specific characteristics. Consequently, the occupational autonomy of paramedics differs between the states.

Prehospital Electrocardiogram Transmission and Prehospital Scene Time: A Retrospective Cohort Study.

Background: Telemedical transmission of prehospital electrocardiograms (ECGs) to a target clinic may improve clinical workflows and speed of intervention. However, whether ECG transmission delays prehospital workflows remains controversial. Therefore, we aimed to clarify whether ECG transmission prolongs prehospital scene time in patients diagnosed with acute coronary syndrome (ACS). Methods: We retrospectively included all patients diagnosed with ACS by prehospital emergency physicians from July 2016 to June 2019 at a single academic center. The primary endpoint was the effect of ECG transmission on prehospital scene time. The secondary endpoints were the effects of ECG diagnosis on prehospital scene time and quality of care. Multivariable regression was used to account for patients' age, physician specialty, completion of specialty training, and whether emergencies occurred throughout the day or night shifts as potential confounders. Results: A total of 1,106 cases were included, of which 154 ECG transmissions were performed. ECG transmission prolonged prehospital scene time by an average of 3 min: adjusted regression coefficient [95% confidence interval (95% CI)]: 3.24 (1.7-4.8), p < 0.001. Prehospital treatment time was not influenced by prehospital ECG-based diagnosis (ST-elevation myocardial infarction [STEMI] vs. non-ST-elevation ACS [NSTE-ACS]): adjusted regression coefficient (95% CI): 0.7 (-1.3 to 2.7), p = 0.490. Emergency physicians adhered to local standard operating procedures in 739 of 1,007 (73%) patients diagnosed with NSTE-ACS and 93 of 99 (94%) patients diagnosed with STEMI. A STEMI diagnosis compared with NSTE-ACS was associated with five times higher odds of adhering to standard operating procedures (odds ratio [95% CI]: 5.6 [2.7-14.6], p < 0.001). Conclusion: The observed delay of ∼3 min in the prehospital scene time by ECG transmission is clinically irrelevant. For patients prehospitally diagnosed with NSTE-ACS who do not meet STEMI criteria, adherence to standard operating procedures seems unjustifiably low and should be improved.

Associations between professional identity and turnover intent in prehospital emergency physicians: The mediating effect of burnout.

The prehospital emergency system is essential for reducing mortality and disability in emergency patients. However, the high turnover rate of prehospital emergency physicians (PEPs) remains the most prominent problems in the prehospital emergency system. Turnover intent (TI) is predictive of actual turnover behavior; however, previous studies have mainly focused on sociodemographic factors and job characteristics, ignoring many other potential psychological factors, such as professional identity (PI) and job burnout (JB). To measure the level of PI, JB, and TI of PEPs in Beijing, China. We analyze the distribution of TI in different social demography PEPs and then further explore the influence of PI and JB on TI, to provide a reference and suggestions for government departments to reduce the TI of PEPs. An online questionnaire was distributed to 552 PEPs in Beijing, and a total of 533 valid questionnaires were included. T-test and variance analysis were used to examine the differences in the distribution of TI among different sociodemographic PEPs. Pearson's correlation analysis was used to test the correlation between PI, JB, and TI. The SEM was used to analyze the relationships among PI, JB, and TI. Univariate analysis showed that age, marital status, education, professional title, work experience, department and hukou were significantly associated with TI. Pearson's correlation analysis showed that PI was negatively associated with JB and TI, and JB was positively associated with TI. Professional treatment identity (PTI, β = -0.24, 95% CI: -0.38~-0.11), professional meaning identity (PMI, β = -0.12, 95% CI: -0.23~0.03), and emotional exhaustion (EE, β = 0.40, 95% CI: 0.28~0.51) seem to have direct impacts on TI. Given the mediating role played by EE, PTI may have an indirect negative effect on TI (β = -0.24, 95% CI: -0.32~0.16). PI and JB of PEPs in China are closely related to TI, which may have unexpected effects on government departments to stabilize the team of PEPs through a series of control measures. According to the above results, the professional treatment of PEPs needs to be improved, and external learning opportunities should be increased. Legalization of medical rescue workers should also be on the agenda.

Sicherheitsaspekte invasiver thorakaler Maßnahmen in der prähospitalen Notfallmedizin – Ergebnisse einer Umfrage unter deutschen Notärzt:innen

BackgroundThe safe indication and performance of thoracic emergency procedures are crucial and potentially lifesaving in prehospital emergency care. This study aims to investigate issues of patient safety and quality assurance of prehospital invasive thoracic interventions. The survey does not represent the actual medical care situation but explores reasons for security concerns among emergency physicians. MethodsUsing a pre-validated questionnaire, prehospital emergency physicians of three prehospital rescue associations (Zweckverband) in Southwest Saxony, Greifswald, and Vechta, Germany, were queried via the online survey service limesurvey. The survey was conducted between January and March 2022. Results104 emergency physicians participated (response rate 42.4%) 71 of which fully completed the survey (68%). 79% of the participants stated that they felt safe in performing pleural punction. Common reasons for postponing prehospital thoracic interventions included fear of complications or individual patient characteristics. 90% said that they were familiar with the on-board equipment options, and 60% reported that resources were sufficient to perform double-sided procedures. While in all three regions there is sufficient on-board equipment to perform procedures on two sides, one out of two participants said that lack of equipment deters them from performing prehospital invasive thoracic procedures. Emergency physicians who graduated from trauma courses and/or participate in air rescue are more likely to perform invasive thoracic procedures. More than half of the participants wanted more training in chest tube placement or pleural punction. ConclusionSafety in prehospital invasive thoracic procedures needs improvement in structural, procedural, as well as human factors aspects. Safe handling of these rare but vital techniques requires more training. A lack of knowledge of equipment is a significant safety gap. Prehospital ultrasound constitutes a structural element of prehospital diagnostics.

ST-T segment changes in prehospital emergency physicians in the field: a prospective observational trial

AimsDue to time-critical decision-making, physical strain and the uncontrolled environment, prehospital emergency management is frequently associated with high levels of stress in medical personnel. Stress has been known to cause ischemia like changes in electrocardiograms (ECGs), including arrhythmias and deviations in ST-T segments. There is a lack of knowledge regarding the occurrence of changes in ST-T segments in prehospital emergency physicians. We hypothesized that ST-T segment deviations occur in prehospital emergency physicians in the field.MethodsIn this prospective observational trial, ST-T segments of emergency physicians were recorded using 12-lead Holter ECGs. The primary outcome parameter was defined as the incidence of ST-T segment changes greater than 0.1 mV in two corresponding leads for more than 30 s per 100 rescue missions. The secondary outcomes included T-wave inversions and ST-segment changes shorter than 30 s or smaller than 0.1 mV. Surrogate parameters of stress were measured using the NASA-Task Load Index and cognitive appraisal, and their correlation with ST-T segment changes were also assessed.ResultsData from 20 physicians in 36 shifts (18 days, 18 nights) including 208 missions were analysed. Seventy percent of previously healthy emergency physicians had at least one ECG abnormality; the mean duration of these changes was 30 s. Significantly more missions with ECG changes were found during night than day shifts (39 vs. 17%, p < 0.001). Forty-nine ECG changes occurred between missions. No ST-T segment changes > 30 s and > 0.1 mV were found. Two ST-T segment changes < 30 s or < 0.1 mV (each during missions) and 122 episodes of T-wave inversions (74 during missions) were identified. ECG changes were found to be associated with alarms when asleep and NASA task load index.ConclusionECG changes are frequent and occur in most healthy prehospital emergency physicians. Even when occurring for less than 30 s, such changes are important signs for high levels of stress. The long-term impact of these changes needs further investigation.Trial registration The trial was registered at ClinicalTrials.gov (NCT04003883) on 1.7.2019: https://clinicaltrials.gov/ct2/show/NCT04003883?term=emergency+physician&rank=2

Differences in training among prehospital emergency physicians in Germany.

BackgroundGermany has an interdisciplinary physician-based emergency medical service. Differences in training likely lead to different levels of expertise.ObjectivesWe assessed the number of manual procedures performed at the completion of training to determine level of experience of prehospital emergency physicians of different primary specialties.Materials and methodsImmediately after passing the board examination each examinee was asked to estimate the number of performed procedures for 26 manual skills. We compared the results with recommendations and data on learning manual skills. Results are presented as mean (standard deviation).ResultsEndotracheal intubation via direct laryngoscopy was performed 1032 (739) times by anesthesiologists. Surgeons and internists performed 89 (89) and 77 (65) intubations, respectively. Intubation via video laryngoscopy was performed 79 (81) times by anesthesiologists, 11 (17) times by surgeons and 6 (11) times by internists. Surgeons had little experience in non-invasive ventilation, with 9 (19) performed procedures and had rarely used external pacemaker therapy or electrical cardioversion. In comparison, among all participants non-invasive ventilation was performed 152 (197) times, electrical cardioversion was performed 41 (103) times and an external pacemaker was used 6 (15) times. For other procedures the numbers did not markedly differ between the different specialties.ConclusionThe number of performed procedures markedly differed for some skills between different primary specialties. Recommendations regarding a procedural volume were not always met, suggesting missing expertise for some skills. A defined number of procedures should therefore be a formal requirement to be eligible for board certification in prehospital emergency medicine.

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50–64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69–0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Assessment of emergency physicians’ performance in identifying shockable rhythm in out-of-hospital cardiac arrest: an observational simulation study

BackgroundEmergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with...

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest.

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

Die prähospitale Therapie eines Spannungspneumothorax bei Kindern – welche Entscheidungen treffen wir?

The preclinical treatment of atraumatic or spontaneous tension pneumothorax remains aparticular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training. In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians. An online survey was conducted with 43questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich. More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children. Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers alarge amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing atension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.

Development of a pre-hospital emergencies protocol for the management of suicidal patients in Iran

BackgroundSuicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation.MethodWe reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks.ResultsThe basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered.ConclusionA locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.