Øyvind Thomassen

The effects of safety checklists in medicine: a systematic review.

Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes.

Ketamine: use in anesthesia.

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

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.

Equipment to prevent, diagnose, and treat hypothermia: a survey of Norwegian pre-hospital services

IntroductionHypothermia is associated with increased morbidity and mortality in trauma patients and poses a challenge in pre-hospital treatment. The aim of this study was to identify equipment to prevent, diagnose, and treat hypothermia in Norwegian pre-hospital services.MethodIn the period of April-August 2011, we conducted a survey of 42 respondents representing a total of 543 pre-hospital units, which included all the national ground ambulance services, the fixed wing and helicopter air ambulance service, and the national search and rescue service. The survey explored available insulation materials, active warming devices, and the presence of protocols describing wrapping methods, temperature monitoring, and the use of warm i.v. fluids.ResultsThroughout the services, hospital duvets, cotton blankets and plastic “bubble-wrap” were the most common insulation materials. Active warming devices were to a small degree available in vehicle ambulances (14%) and the fixed wing ambulance service (44%) but were more common in the helicopter services (58-70%). Suitable thermometers for diagnosing hypothermia were lacking in the vehicle ambulance services (12%). Protocols describing how to insulate patients were present for 73% of vehicle ambulances and 70% of Search and Rescue helicopters. The minority of Helicopter Emergency Medical Services (42%) and Fixed Wing (22%) units was reported to have such protocols.ConclusionThe most common equipment types to treat and prevent hypothermia in Norwegian pre-hospital services are duvets, plastic “bubble wrap”, and cotton blankets. Active external heating devices and suitable thermometers are not available in most vehicle ambulance units.

Does the horizontal position increase risk of rescue death following suspension trauma

Background: It is widely believed that placing a patient who has been subjected to suspension trauma in a horizontal position after rescue may cause rescue death. The discussion whether position is important has been dominated by non-medical personnel. Subsequently, this has led to a general advice on emergency treatment of these patients, which may cause incorrect or even fatal treatment. Methods: To determine whether there is any medical evidence supporting that horizontal positioning after suspension trauma may cause rescue death, the authors located publications, reports, expert opinions and other sources of information addressing the acute treatment of suspension trauma. These sources were then evaluated. Results: Several thousand hits regarding suspension trauma were located on the internet and five articles on the PubMed. Although most of them warned of the dangers of rescue death brought about by assuming the horizontal position after prolonged suspension, the authors found no clinical studies, and none of the sources offered any conclusive evidence as to whether the horizontal position increases the risk of rescue death. Neither the authors, nor the suspension trauma experts who were contacted, had ever experienced or heard of case reports supporting the causal relation between the horizontal position and rescue death. Conclusions: After evaluating the current literature, the authors found no support for the view that the horizontal position may be potentially fatal for patients exposed to suspension trauma. In the absence of any evidence to the contrary, the authors suggest that the initial management of patients who have had suspension trauma should follow normal guidelines for the acute care of traumatised patients, without special modifications.

Avalanche accidents and treatment of avalanche victims

Avalanches may be provoked spontaneously or as a result of human activity, and they trigger the need for considerable rescue resources. Avalanche search and rescue operations are complex and characterised by physical and mental stress. The guidelines for resuscitation of avalanche victims may be perceived as complex and abstruse, which can lead to suboptimal treatment and an increased strain on rescue teams. The purpose of this article is to summarise the principles for medical treatment of avalanche victims.

Implementation of safety checklists in medicine: not as simple as it sounds

BACKGROUND and objective: Adverse events are documented to affect more than 1 in 25 hospital patients. Medical mishaps and errors are rarely the result of incompetence, poor motivation, or negligence but of challenges on social and cognitive skills such as loss of situation awareness, poor communication, less-than-optimal teamwork, problematic stress management, and memory overload. Realising how prone we as humans are for shortterm memory loss, it is striking how many potentially dangerous medical procedures are based on ‘perfect’ memory. The aims of this thesis were to develop and measure the effect of a pre-induction safety checklist in anaesthesia, explore the personnel’s acceptance and experience with this list, and further examine experiences with checklists in some non-medical high reliability organisations (HROs). HROs are organisations achieving high levels of safety despite facing considerable hazard and operational complexity. Methods: Statistical process control was chosen as a quantitative approach to measure the effect of the pre-induction checklist implementation. Qualitative approaches using focus groups, key informant interviews, Delphi technique, and consensus process were utilized to develop the checklist and examine checklist experiences. Results: During a study period of 13 weeks, the 26-item checklist was used in 502 (61%) of 829 anaesthesia inductions. One or more missing items were identified in 17% (range 4–46%) of these procedures. It took a median of 88.5 seconds (range 52–118) to perform the checklist. Some participants were concerned that patients might have become anxious about possible unpreparedness because there was a ‘need’ for a final check. The participants had, on their own initiative, adopted strategies to reduce this potential burden to the patients. The introduction of the checklist interrupted workflow by disturbing some of the personnel’s own streamlined working habits or by causing redundant checks done by both nurses and physicians. Some participants had experienced negative or ironic comments from colleagues. They emphasised the importance of a supporting and motivating unit leader. Several of the participants had experienced increased confidence in performing challenging cases in unfamiliar places and situations. The participants discovered that the seven various operating theatres in which the checklist was used were not designed and equipped in the same way. This highlighted the need for standardisation if the same checklist should be used in every operating theatre. The interviews with personnel from six HROs generated 84 assertions in checklist development and implementation. Several of the informants underlined the importance of an early assessment if Thesis defended: 19 January 2012. Respondent: Øyvind Thomassen, MD, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. Department of Surgical Sciences, University of Bergen, Bergen, Norway. Norwegian Air Ambulance Foundation, Drøbak, Norway. Main supervisor: Jon Kenneth Heltne, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. Department of Medical Sciences, University of Bergen, Bergen, Norway. Opponents: Eefje de Vries, PhD, Spaarne Ziekenhuis, Hoofddorp, The Netherlands. Sven Erik Gisvold, Professor, NTNU, Trondheim, Norway. Henning Onarheim, Professor, University of Bergen, Bergen, Norway.

Mountain rescue cardiopulmonary resuscitation: a comparison between manual and mechanical chest compressions during manikin cardio resuscitation

Aim Chest compression devices are useful during mountain rescue but may cause a delay in transport if not immediately available. The aims of this prospective observational study were to compare manual and mechanical cardiopulmonary resuscitation (CPR) during transport on a sledge connected to a snowmobile with a non-moving setting and to compare CPR quality between manual and two mechanical chest compression devices. Methods Sixteen healthcare providers simulated four different combined CPR scenarios on a sledge in a non-moving setting and during transport and two mechanical chest compression devices during transport on the sledge. The study was conducted in May 2015 in a mountain in Norway. The primary outcome measures were compression rate (compressions per minute), compression depth in millimetres, leaning (incomplete chest wall release after compression in millimetres) and chest compression fraction (fraction of total time were compression were performed). The results were analysed by descriptive and graphical methods and paired t-tests were used to compare the differences between techniques. Results We did not observe a significant difference between moving and non-moving conditions with respect to manual compression rate (p=0.34), compression depth (p=0.50) or leaning (p=0.92). However, both the manual compression depth (p<0.001) and the leaning (p=0.04) showed a significantly larger variance during the moving runs. Conclusion Manual chest compression is possible on a snowmobile during transport even in challenging terrain. This experimental study shows that high-quality chest compressions and manual ventilation can be performed in an intubated patient during a short-term transportation on a sledge.