Anders Jonsson

Decision support system in prehospital care: a randomized controlled simulation study.

INTRODUCTIONnPrehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS.nnnMETHODSnIn this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST).nnnRESULTSnThere was no significant difference in the two groups characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001).nnnCONCLUSIONnThe results indicate that this CDSS increases the ambulance nurses compliance with regional prehospital guidelines but at the expense of an increase in OST.

Performance indicators for prehospital command and control developed for civilian use tested in a military training setting : a pilot study

Objectives The aim of this study was to determine if a set of performance indicators for command and control (C2) primarily developed for civilian use could be applied also to a military training context as well. Method The initial decision-making in the on-scene medical management in a multinational military medical evacuation exercise in Afghanistan was studied, using this set of indicators. Results Two performance indicators were appropriate to this setting. Of the nine applicable indicators, the standards set for civilian use were met in four, in three other they were not met, and there was a lack of documentation in two indicators. Conclusion Measurable performance indicators for prehospital command and control were to some extent found to be applicable also to a military environment. Future developments may make it possible for the concept of measuring results using civilian performance indicators to become a quality control tool in a military setting.

Interaction, Action, and Reflection: How Medics Learn Medical Care in the Swedish Armed Forces

The objective of this study is to examine how medics within the Swedish Armed Forces perceive their learning outcome following military prehospital training. A qualitative study with a phenomenographic approach was used to investigate how learning is perceived among military medics. At meta level, the results can be viewed as an interaction, i.e., being able to collaborate in the medical platoon, including the ability to interact within the group and being able to lead; an action, i.e., being able to assess and treat casualties, including the ability to communicate with the casualty, to prioritize, and to be able to act; and a reflection, i.e., having confidence in ones own ability in first aid, including being prepared and feeling confident. Interaction during the period of education is important for learning. Action, being able to act in the field, is based on a drill in which the subject progresses from simple to complex procedures. Reflection, learning to help others, is important for confidence, which in turn creates preparedness, thereby making the knowledge meaningful.

Doctors’ and nurses’ perceptions of military pre-hospital emergency care – When training becomes reality

The aim of this study was to identify physicians and nurses perceptions of military pre-hospital emergency care before and after an international mission. A qualitative empirical study with a phenomenographic approach was used. The results after pre-deployment training can be categorised as (1) learning about military medicine and (2) taking care of the casualty. The results after an international mission can be categorised as (1) collaborating with others, (2) providing general health care and (3) improving competence in military medicine. These results indicate that the training should be developed in order to optimise pre-deployment training for physicians and nurses. This may result in increased safety for the provider of care, while at the same time minimising suffering and enhancing the possibility of survival of the injured.

Experiences of Swedish Military Medical Personnel in Combat Zones: Adapting to Competing Loyalties

OBJECTIVESnThe aim of this qualitative study is to explore the Swedish military personnels experience of what it means to perform a caring role in a combat zone. This study assesses the challenges faced by military medical personnel in the context of a combat zone.nnnMETHODSnThe design was descriptive with a qualitative inductive approach. Twenty military medical personnel (physicians, nurses, and combat lifesavers) were interviewed individually. They had been involved in international military operations between 2009 and 2012. This study was analyzed using qualitative content analysis.nnnRESULTSnThe analysis produced four categories: being in a primarily noncaring organization, caring in emotionally charged relationships, lacking an open dialog about expectations of killing and having to prioritize scarce resources.nnnCONCLUSIONSnThis study shows that medical personnel easily adapt to a military setting. They care but also perform other tasks when they are in a combat zone. The medical personnel want to give care to host nation but use drugs they can spare.

Fixing the Wounded or Keeping Lead in the Air : Tactical Officers’ Views of Emergency Care on the Battlefield

The aim of this study was to identify tactical officers views of prehospital emergency care in the field before an international mission. A qualitative study with a phenomenographic approach based on interviews was used. The result of this study is a set of descriptive categories on a collective level, showing the variation in how the tactical officers perceived the phenomenon of emergency care in the battlefield. The result can be viewed as (1) noncombat-oriented including being able to do ones specialist task, being able to talk with local people, and being able to give first aid, and (2) combat-oriented including soldiers skills and roles in the unit, being able to act in the unit, and being able to lead the care of injured. These findings are important for officers preparation for international missions. The interaction between military and medical knowledge on-site care should be developed between the tactical officer and the medical personnel in order to minimize suffering and to enhance the possibility for survival of the casualty.

A hybrid simulator model for the control of catastrophic external junctional haemorrhage in the military environment

Catastrophic haemorrhage from extremity injuries has for a long time been the single most common cause of preventable death in the military environment. The effective use of extremity tourniquets has increased the survival of combat casualties, and exsanguination from isolated limb injuries is no longer the most common cause of death. Today, the most common cause of potentially preventable death is haemorrhage from the junctional zones, i.e. the most proximal part of the extremities, not amenable to standard tourniquets.Different training techniques to control catastrophic haemorrhage have been used by the Swedish Armed Forces in the pre-deployment training of physicians, nurses and medics for many years. The training techniques include different types of human patient simulators such as moulage patients and manikins. Preferred training conditions for the control of catastrophic haemorrhage include a high degree of realism, in combination with multiple training attempts.This report presents a new hybrid training model for catastrophic external junctional haemorrhage control. It offers a readily reproducible, simple and inexpensive opportunity to train personnel to deal with life threatening catastrophic junctional haemorrhage. In particular, this model offers an opportunity for non-medical military personnel in Sweden to practice control of realistic catastrophic haemorrhage, with multiple training attempts.

Using Shoulder Straps Decreases Heart Rate Variability and Salivary Cortisol Concentration in Swedish Ambulance Personnel

Background Previous research has shown that paramedics are exposed to risks in the form of injuries to the musculoskeletal system. In addition, there are studies showing that they are also at increased risk of cardiovascular disease, cancer, and psychiatric diseases, which can partly be explained by their constant exposure to stress. The aim of this study is to evaluate whether the use of shoulder straps decreases physical effort in the form of decreased heart rate and cortisol concentration. Methods A stretcher with a dummy was carried by 20 participants for 400 m on two occasions, one with and one without the shoulder straps. Heart rate was monitored continuously and cortisol samples were taken at intervals of 0 minutes, 15 minutes, 30 minutes, 45 minutes, and 60 minutes. Each participant was her or his own control. Results A significant decrease in heart rate and cortisol concentration was seen when shoulder straps were used. The median values for men (with shoulder straps) at 0 minutes was 78 bpm/21.1 nmol/L (heart rate/cortisol concentration), at 15 minutes was 85 bpm/16.9 nmol/L, and at 60 minutes was 76 bpm/15.7 nmol/L; for men without shoulder straps, these values were 78 bpm/21.9 nmol/L, 93 bpm/21.9 nmol/L, and 73 bpm/20.5 nmol/L. For women, the values were 85 bpm/23.3 nmol/L, 92 bpm/20.8 nmol/L, and 70 bpm/18.4 nmol/L and 84 bpm/32.4 nmol/L, 100 bpm/32.5 nmol/L, and 75 bpm/25.2 nmol/L, respectively. Conclusion The use of shoulder straps decreases measurable physical stress and should therefore be implemented when heavy equipment or a stretcher needs to be carried. An easy way to ensure that staff use these or similar lifting aids is to provide them with personalized, well-adapted shoulder straps. Another better option would be to routinely sewn these straps into the staffs personal alarm jackets so they are always in place and ready to be used.

Training Methods for the Control of Catastrophic Haemorrhage in the Military Environment

s of Scientific Papers 18th World Congress on Disaster and Emergency Medicine ID 3: Medical Support of Euro-2012 Ukrainian Experience Georgiy Roshchin, Oleg Mazurenko, Mycola Blyznyuk, Daniel Smiley 1. Ukrainian emergency and disaster medicine centre, NMAPE named after P.L.Shupic 2. National medical academy for post graduate education named after P.L.Shupic (Ukraine) 3. Ukrainian emergency and disaster medicine centre 4. California EMS Authority (United States) Background: The European Football Championship Euro2012 was one of the most significant Mass Gathering Events (MGE) in Ukraine. The main public health tasks were defined as: 1) emergency care; 2) readiness for medical response in case of a huge incident like a terrorist attack. Methods: The study was performed utilizing both quantitative and qualitative data. Medical support of Euro-2012 involved: 171 hospitals, including 50 hospitals in the host cities Kyiv, Donetsk, Kharkiv and Lviv, and 121 were located on transport routes. Total hospital beds were 39059. In accepting cities 38.9% (5840) beds were reserved. 92 first-aid stations were established additionally at the stadiums (34 (37%)), airports and railway stations (12 (13%)), on the fan zones (14 (15.2%)), and on the state border (32 (34.8%)). Field hospitals of the National Disaster Medicine Service were located near to stadiums. 319 ambulance teams were involved. These teams operated at stadiums, in the ‘‘fan zones’’ and ‘‘fan camping’’, along the route of movement. Results: Total amount of tourists were 1.8 million. Medical assistance was provided to 1217 people (including 11 children). 40000 medical staffs were involved for medical assistance, including 11540 physicians (28.8%) and 28460 nurses (71.1%). Internal disease and injury prevailed among patients of MGE. We will show epidemiology of patients during Euro-2012 from the public health management point of view. Conclusion: This study illustrated that involvement of 2.16% medical staff and 2.17% hospital bed was sufficient in relation to total amount of MCE participant for medical support to Euro-2012 in Ukraine. Prehosp Disaster Med 2013;28(Suppl. 1):s1 *doi:10.1017/S1049023X13003592 ID 4: Reliability of Emergency Severity Index Triage System – Meta-Analysis Amir Mirhaghi, Abbas Heydari 1. Mashhad University of Medical Sciences (Iran) 2. Mashhad University of Medical Sciences Background and Aim: Rapidity, ease and quantitative criteria based on vital signs are the most important advantages which facilitate the pervasive development of the emergency severity index (ESI) triage. The question is the extent to which this system is reliable in various emergency departments given that development has mainly occurred in the USA. Our aim is to gain insights from examining combined average of reliability coefficients of the emergency severity index in various emergency departments in order to achieve a more general understanding of the emergency severity index reliability. Method: this review has been conducted based on metaanalysis Of Observational Studies in Epidemiology (MOOSE) guidelines. All studies about the emergency severity index reliability based on inclusion/exclusion criteria are examined. In selected articles, data about population, reliability method, kappa statistics and location are included. The key terms for search were triage, emergency severity index and reliability. Only full texts have been reviewed. Results: 12 studies including 20340 triage decision-making situations were examined. Range and median for decisionmaking situations were from 62 to 6200 and 351. Range and combined average for inter-observer agreement percentage was from 73% to 83% and 82%. Range and median for kappa statistics were 0.985 (almost perfect) to 0.46 (moderate) and 0.83 (almost perfect). Combined average for kappa statistics was 0.72 (substantial). Only 2 of 12 studies were conducted outside of the USA (17%). Discussion: Although the ESI triage system as a new approach has shown an acceptable reliability compared to traditional methods. However the use of weighted versus un-weighted kappa statistics, the focus of studies in the United States rather than other countries, the use of written scenario versus actual patients and methodological limitations in using reliability assessment methods indicates a need for more developed research to assess reliability. Prehosp Disaster Med 2013;28(Suppl. 1):s1 doi:10.1017/S1049023X13003609 ID 5: Civilian Military Collaboration in the Education of Disaster Medicine in Saga University, Japan Koichi Shinchi, Toyoka Shinchi, Norihito Noguchi, Ayumi Yamamoto, Kazutoshi Masuda, Kazuyuki Akinaga, Kaoru Shibayama, Rika Minamijima, Yoko Hanada, Hitmoi Matsunaga, Setsuko Umezaki 1. Division of International Health and Nursing, Saga University (Japan) 2. Saga University, Japan 3. Saga University May 2013 Prehospital and Disaster Medicine 4. Saga University 5. Saga University 6. Saga Univrsity 7. Saga Univeristy 8. Saga University 9. Saga University 10. Saga University 11. Junshin Gakuen University Background: The authors report civilian military collaboration in practical disaster medical education in Saga University, Japan. After the Hanshin Awaji Great Earthquake Disaster in 1995, education in disaster medicine in medical college became very important. Especially, practical exercises in collaboration with military medical teams became very important. Method: The authors facilitated practical disaster medical education including simulated exercises of Disaster Medical Assistance Team (DMAT) activities, Disaster Imagination Games, triage, and communication training using transceivers from 2008. The education also included lectures and exercises in Japan Ground Self Defense Forces (GSDF) Metabaru Station. The exercises included patient transportation training using helicopters and wheel beds. Subjects were 7 nursing students and 5 post-graduated master and doctor course students. The period of the education was from June 27 to July 24, 2012. The authors examined the effectiveness of the civilian military collaboration in this disaster medical education by collecting the data from the reports submitted by all subjects after the education. Result: All of the students answered that this education in GSDF Metabaru Station was ‘‘very important’’ and ‘‘very instructive’’. They also answered that the patients transportation exercise by the military helicopters and wheel beds were very instructive, and 91.7% of them answered that this practical training was very interesting. After the education, they reported that lectures concerning the role of GSDF in large scale disasters and international peace keeping operations were very important. Conclusion: Civilian military collaboration in the education of disaster medicine and training medical students who can work effectively in disaster areas is considered very important. We must promote civilian military collaboration in disaster medical education for the future practical disaster relief activities. Prehosp Disaster Med 2013;28(Suppl. 1):s1–s2 doi:10.1017/S1049023X13003610 ID 6: The National Health Services (NHS) in London 2012 Olympics Evaluation Konstantinas Kononovas, Georgia Black, Jayne Taylor, Rosalind Raine 1. Department of Applied Health Research, University College London (United Kingdom) 2. Department of Applied Health Research, University College London 3. Department of Applied Health Research, University College London 4. Department of Applied Health Research, University College London Background: The objective of this research is to evaluate NHS London’s 2012 Programme. This programme was charged with assuring that NHS services in London could provide business as usual, and would be prepared for emergencies and public health risks during the Olympics. Methods: We gathered data from three main sources before, during and after the Games to enable a longitudinal perspective. Data sources include: > key individuals working for and with NHS London 2012 Programme, to explore planning and delivery from a wide range of perspectives; > NHS London documentation through the duration of programme; > previous Olympic healthcare reports from Sydney, Athens, Beijing and Vancouver, to analyse key issues identified from previous Games and to enable their comparison with the London Games. > A thematic analysis was undertaken including triangulation of the three data sources. Results: We will present our results in the following areas: > descriptions of the plans to (i) address impact on local NHS routine and emergency health services, (ii) the emergency planning arrangements for participants and visitors to the Games, (iii) public health enhancement and protection during the Games and (iv) the range of interventions and health legacy initiatives undertaken; > a critical evaluation of the processes, barriers, facilitators and outcomes of the planning and delivery activities, and analysis of re-occurring issues in every Olympic Games. Conclusion: Our results have implications for: 1. Mass gatherings health planning: including recommendations about planning assumptions, organisation and management, maintenance of business-as-usual, public health and legacy; 2. The NHS: including generalisable lessons and long-term benefits; 3. The development of qualitative methods of the evaluation of major, rapid and complex intervention and service change. Prehosp Disaster Med 2013;28(Suppl. 1):s2 doi:10.1017/S1049023X13003622 ID 7: Rescuing Disabilities Maria Cristina Saenz CEAC Consultancy in Emergencies (Argentina) Background: People with disabilities must have equal access to Human Rights and fundamental liberties. This program gives psychosocial support and diminishes risks in a vulnerable group. We are among a public Health problem and searching for a better life quality and suffering diminish in people with low possibilities of being rescued. It is calculated that a 10% of population suffers some kind