Erik Zakariassen

Comparison of three different prehospital wrapping methods for preventing hypothermia - a crossover study in humans

BackgroundAccidental hypothermia increases mortality and morbidity in trauma patients. Various methods for insulating and wrapping hypothermic patients are used worldwide. The aim of this study was to compare the thermal insulating effects and comfort of bubble wrap, ambulance blankets / quilts, and Hiblers method, a low-cost method combining a plastic outer layer with an insulating layer.MethodsEight volunteers were dressed in moistened clothing, exposed to a cold and windy environment then wrapped using one of the three different insulation methods in random order on three different days. They were rested quietly on their back for 60 minutes in a cold climatic chamber. Skin temperature, rectal temperature, oxygen consumption were measured, and metabolic heat production was calculated. A questionnaire was used for a subjective evaluation of comfort, thermal sensation, and shivering.ResultsSkin temperature was significantly higher 15 minutes after wrapping using Hiblers method compared with wrapping with ambulance blankets / quilts or bubble wrap. There were no differences in core temperature between the three insulating methods. The subjects reported more shivering, they felt colder, were more uncomfortable, and had an increased heat production when using bubble wrap compared with the other two methods. Hiblers method was the volunteers preferred method for preventing hypothermia. Bubble wrap was the least effective insulating method, and seemed to require significantly higher heat production to compensate for increased heat loss.ConclusionsThis study demonstrated that a combination of vapour tight layer and an additional dry insulating layer (Hiblers method) is the most efficient wrapping method to prevent heat loss, as shown by increased skin temperatures, lower metabolic rate and better thermal comfort. This should then be the method of choice when wrapping a wet patient at risk of developing hypothermia in prehospital environments.

Norwegian regular general practitioners' experiences with out-of-hours emergency situations and procedures.

Objective: To study the participation of Norwegian regular general practitioners (RGPs) in the out-of-hours system in 2006 and what kind of emergency situations and procedures they experienced in the past 12 months. RGPs’ confidence in performing certain emergency procedures was also mapped. Methods: In May 2006 all 3804 RGPs taking part in the RGP scheme in Norway were sent a questionnaire dealing with several aspects of the emergency out-of-hours duty. The RGPs who had participated were asked about 14 pre-selected emergency situations, experiences with different pre-selected emergency procedures and their self-confidence with these in the past 12 months. Results: After two reminders 2913 (78%) answered and 1832 (63%) confirmed they had taken part in emergency out-of-hours services in the past 12 months. 95% of participating RGPs answered questions about emergency situations, 74–78% about emergency procedures. The most common situations were chest pain, psychiatric problems and asthma, experienced by 94%, 92% and 88%, respectively. The number of occasions the doctors had experienced the most frequent emergency procedures (presented as median 25–75% percentiles) were: intravenous medication, three (1–10); oxygen mask, three (1–10); venous access, four (1–10). The doctors reported almost no experiences with other procedures. The doctors reported a high self-confidence in performing the emergency procedures. Male doctors working four or more shifts per month and doctors working in rural areas reported more experiences both in emergency situations and procedures. Conclusion: Approximately two-thirds of RGPs in Norway took part in the out-of-hours service. A wide variety of emergency cases was experienced by the RGPs. Despite this, experiences with most emergency procedures during a 12-month period are low. Regular training is therefore necessary to maintain good skill levels.

Helicopter emergency medical services response times in Norway: Do they matter?

OBJECTIVE The main objective of the Norwegian air ambulance service is to provide advanced emergency medicine to critically ill or severely injured patients. The government has defined a time frame of 45 minutes as the goal within which 90% of the population should be reached. The aims of this study were to document accurate flying times for rotor wing units to the scene and to determine the rates of acute primary missions in Norway. METHODS We analyzed operational data from every acute primary mission from all air ambulance bases in Norway in 2011, focusing on the flying time taken to reach scene, the municipality requesting the flight, and the severity score data. RESULTS A total of 5,805 acute primary missions were completed in Norway in 2011. The median flying time was 19 minutes (25%-75% percentiles: 13-28). The mean mission rate for the 17 bases was 7.5 (95% confidence interval, 7.4-7.8 per 10,000 inhabitants). The overall mean (standard deviation) National Committee on Aeronautics score for all missions was 4.07 (1.30). CONCLUSION The governments expectation of serving the entire population via HEMS within 45 minutes appears to be achieved on a national level. However, vast differences remain in the flying times and rates between bases.

Assessment of acute stroke cerebral CT examinations by anaesthesiologists

It is essential to diagnose ischaemic stroke as soon as possible after symptom onset, so that thrombolytic treatment can be initiated as quickly as possible. This might be greatly facilitated if cerebral CT could be carried out in a pre‐hospital setting. The aim of this study was to evaluate if anaesthesiologists, who in Norway provide pre‐hospital medical care, could be trained to assess cerebral CT scans to exclude radiological contraindications for thrombolytic stroke treatment.

Cooperation between ambulance personnel and regular general practitioners

BACKGROUND The ambulance service in Norway has gone through a pronounced upgrading of skills and professionalization during the last 10 years. The purpose of this survey was to obtain knowledge on how the ambulance personnel perceive their own professional competence and their relationship to other occupational groups with whom they cooperate. MATERIAL AND METHOD A questionnaire was sent to 300 persons who received authorization as ambulance personnel between 2002 - 2005. Questions were included on evaluation of inter-professional cooperation, professional appreciation and competence in practical handling of patients. RESULTS The response rate was 52 %. The ambulance personnel regarded the most problematic relationships and situations to be with nurses and regular general practioners in the out-of-hours services and with doctors in connection with emergencies at accident sites. 78 % of the ambulance personnel claimed that their own occupational group has the highest competence in the practical handling of patients with acute illness and injuries outside of hospitals. Nevertheless, only 19 % of them felt that occupational groups with who they cooperate appreciate their competence. INTERPRETATION Ambulance personnel have strong confidence in their own occupational groups competence in practical handling of patients. Strengthened formal competence combined with increased possibilities for initial medical treatment in the ambulances, may have contributed to an expanded role for ambulance personnel within pre-hospital emergency care. Smooth cooperation between regular general practitioners and ambulance personnel requires that both parties increase their understanding of the other groups procedures and roles.

GPs' use of defibrillators and the national radio network in emergency primary healthcare in Norway.

Objective. To study the geographic size of out-of-hours districts, the availability of defibrillators and use of the national radio network in Norway. Design. Survey. Setting. The emergency primary healthcare system in Norway. Subjects. A total of 282 host municipalities responsible for 260 out-of-hours districts. Main outcome measures. Size of out-of-hours districts, use of national radio network and access to a defibrillator in emergency situations. Results. The out-of-hours districts have a wide range of areas, which gives a large variation in driving time for doctors on call. The median longest transport time for doctors in Norway is 45 minutes. In 46% of out-of-hours districts doctors bring their own defibrillator on emergency callouts. Doctors always use the national radio network in 52% of out-of-hours districts. Use of the radio network and access to a defibrillator are significantly greater in out-of-hours districts with a host municipality of fewer then 5000 inhabitants compared with host municipalities of more than 20 000 inhabitants. Conclusion. In half of out-of-hours districts doctors on call always use the national radio network. Doctors in out-of-hours districts with a host municipality of fewer than 5000 inhabitants are in a better state of readiness to attend an emergency, compared with doctors working in larger host municipalities.

Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit

In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU).

Exploring optimal air ambulance base locations in Norway using advanced mathematical modelling

Background Helicopter emergency medical services are an important part of many healthcare systems. Norway has a nationwide physician staffed air ambulance service with 12 bases servicing a country with large geographical variations in population density. The aim of the study was to estimate optimal air ambulance base locations. Methods We used high resolution population data for Norway from 2015, dividing Norway into >300 000 1 km×1 km cells. Inhabited cells had a median (5–95 percentile) of 13 (1–391) inhabitants. Optimal helicopter base locations were estimated using the maximal covering location problem facility location optimisation model, exploring the number of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, both in green field scenarios and conditioning on the current base structure. We reanalysed on municipality level data to explore the potential information loss using coarser population data. Results For a 45 min threshold, 90% of the population could be covered using four bases, and 100% using nine bases. Given the existing bases, the calculations imply the need for two more bases to achieve full coverage. Decreasing the threshold to 30 min approximately doubles the number of bases needed. Results using municipality level data were remarkably similar to those using fine grid information. Conclusions The whole population could be reached in 45 min or less using nine optimally placed bases. The current base structure could be improved by moving or adding one or two select bases. Municipality level data appears sufficient for proper analysis.

Out-of-hours doctors' decisions on call-outs in emergency situations

BACKGROUND Several earlier studies have shown that doctors in local out-of-hours emergency primary health care participate in call-outs to varying degrees. It is the out-of-hours doctor who decides whether to respond with a call-out. We wished to study the assessments that form the basis of this decision. MATERIAL AND METHOD We interviewed the out-of-hours doctors in the county of Hordaland who had been alerted about an emergency incident on the health radio network during an evening or night shift, apart from at weekends. The interview period lasted from July to October 2012 and was linked directly to specific alarm calls. RESULTS There were 252 relevant incidents, 72 of which were investigated. A total of 47 of the 95 doctors contacted were interviewed (49%). The doctor responded with a call-out in 65 % of the incidents. Normally it was the content of the message about the patients medical condition that was critical for the doctors decision to respond with a call-out, while it was most often practical aspects that meant that she/he did not respond in this way. When the doctor responded with a call-out, and later assessed the call-out as necessary, the patients need for medical expertise was the most important reason given. INTERPRETATION In the incidents studied, the decision on whether or not to respond with a call-out was based on a balanced consideration of the patients needs and what was practically possible for the doctor. The out-of-hours doctors experienced a need for medical expertise in many emergency medical situations.

Chest pain out-of-hours – an interview study of primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission

BackgroundAcute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians’ approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care.MethodsData were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study.Results“Patient history and symptoms” was considered the most important, and “negative ECG” and “effect of sublingual nitroglycerine” the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing “risk avoiders” against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement “I don’t worry about my decisions after I’ve made them”. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being “over-tested”, and 51% were more likely to admit the patient if the patient herself wanted to be admitted.ConclusionsPhysicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and “tolerance of risk”.