Stephen J. M. Sollid

Oslo government district bombing and Utøya island shooting July 22, 2011: The immediate prehospital emergency medical service response

BackgroundOn July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents.MethodsA retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project.ResultsWe describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately.ConclusionsMany EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

A consensus-based template for uniform reporting of data from pre-hospital advanced airway management

BackgroundAdvanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management.MethodsA four-step modified nominal group technique process was employed.ResultsThe inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and post-intervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential.ConclusionWe successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.

Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service.

BackgroundAnaesthesiologists are airway management experts, which is one of the reasons why they serve as pre-hospital emergency physicians in many countries. However, limited data are available on the actual quality and safety of anaesthesiologist-managed pre-hospital endotracheal intubation (ETI). To explore whether the general indications for ETI are followed and what complications are recorded, we analysed the use of pre-hospital ETI in severely traumatised patients treated by anaesthesiologists in a Norwegian helicopter emergency medical service (HEMS).MethodsA retrospective audit of prospectively registered data concerning patients with trauma as the primary diagnosis and a National Committee on Aeronautics score of 4 - 7 during the period of 1994-2005 from a mixed rural/urban Norwegian HEMS was performed.ResultsAmong the 1255 cases identified, 238 successful pre-hospital ETIs out of 240 attempts were recorded (99.2% success rate). Furthermore, we identified 47 patients for whom ETI was performed immediately upon arrival to the emergency department (ED). This group represented 16% of all intubated patients. Of the ETIs performed in the ED, 43 patients had an initial Glasgow Coma Score (GCS) < 9. Compared to patients who underwent ETI in the ED, patients who underwent pre-hospital ETI had significantly lower median GCS (3 (3-6) vs. 6 (4-8)), lower revised trauma scores (RTS) (3.8 (1.8-5.9) vs. 5.0 (4.1-6.0)), longer mean scene times (23 ± 13 vs. 11 ± 11 min) and longer mean transport times (22 ± 16 vs. 13 ± 14 min). The audit also revealed that very few airway management complications had been recorded.ConclusionsWe found a very high success rate of pre-hospital ETI and few recorded complications in the studied anaesthesiologist-manned HEMS. However, a substantial number of trauma patients were intubated first on arrival in the ED. This delay may represent a quality problem. Therefore, we believe that more studies are needed to clarify the reasons for and possible clinical consequences of the delayed ETIs.

Pre-hospital advanced airway management by anaesthesiologists: is there still room for improvement?

BackgroundEndotracheal intubation is an important part of pre-hospital advanced life support that requires training and experience, and should only be performed by specially trained personnel. In Norway, anaesthesiologists serve as Helicopter Emergency Medical Service HEMS physicians. However, little is known about how they themselves evaluate the quality and safety of pre-hospital advanced airway management.MethodUsing a semi-structured questionnaire, we interviewed anaesthesiologists working in the three HEMS programs covering Western Norway. We compared answers from specialists and non-specialists as well as full- and part-time HEMS physicians.ResultsOf the 17 available respondents, most (88%) felt that their continuous exposure to intubations was not sufficient. Additional training was mainly acquired through other clinical practice and mannequin- or cadaver-based skills training. Of the respondents, 77% and 35% reported having experienced difficult and failed intubations, respectively. Further, 59% reported knowledge of airway management-related deaths in their HEMS program. Significantly more full- than part-time HEMS physicians had experienced these problems. All respondents had airway back-up equipment in their service, but 29% were not familiar with all the equipment.ConclusionThe majority of anaesthesiologists working as HEMS physicians view pre-hospital advanced airway management as a high-risk procedure. Relevant airway management competencies for HEMS physicians in Norway seem to be insufficiently trained and maintained. A better-defined level of competence with better training methods and systems seems warranted.

Capnography rapidly confirmed correct endotracheal tube placement during resuscitation of extremely low birthweight babies (< 1000 g)

During neonatal resuscitation, the routine use of capnography to verify correct placement of the endotracheal tube is not an established international practice. We present four cases that illustrate the successful use of immediate capnography to verify correct tracheal tube placement even in extremely low birthweight (ELBW) prematures (< 1000 g) during resuscitation. Based on this limited experience, we reached institutional consensus among paediatricians and anaesthesiologists that capnography should become standard monitoring during all endotracheal intubations in premature babies.

Risk assessment in critical care medicine: a tool to assess patient safety

In many industries and areas, risk assessment has shown to be a useful decision‐making tool, to compare options and study the need for risk‐reducing measures. In health care, risk assessment is on relatively new ground, and in this paper, we address its use in this area, with emphasis on patient safety. We present a new approach to such assessments for this type of application, using a broad risk perspective where risk is defined as the two‐dimensional combination of (1) events, consequences and (2) associated uncertainties. The approach acknowledges that risk is more than historical‐based probabilities. It is demonstrated using a case from training of health professionals and the use of simulation in the training of physicians performing advanced airway procedures for critically ill patients.

A retrospective observational study of medical incident command and decision-making in the 2011 Oslo bombing

BackgroundA core task for commanders in charge of an emergency response operation is to make decisions. The purposes of the study were to describe what critical decisions the ambulance commander and the medical commander make in a mass casualty incident response and to explore what the underlying conditions affecting decision-making are. The study was conducted in the context of the 2011 government district terrorist bombing in Norway.MethodsThe study was a retrospective, descriptive observational study collecting data through participating observation, semi-structured interviews, and recordings of emergency medical services’ radio communications. Analysis was conducted using systematic text condensation. The ambulance commander was interviewed using the critical decision method.ResultsThe medical emergency response lasted 6.5 h, with little clinical activity after 2 h. Most critical decisions were made within the first 30 min, with the ambulance commander making the bulk of decisions. Situation assessment and underlying uncertainties strongly affected decision-making, but there was a mutual interaction between these three factors that developed throughout the different stages of the operation. Knowledge and experience were major determinants of how easily commanders picked up sensory cues and translated them into situation assessments. The number and magnitude of uncertainties were largest in the development stage, after most of the critical decisions had been made.ConclusionsIn the studied mass casualty incident, the commanders made most critical decisions in the early stages of the emergency response when resources did not meet demand. Decisions were made under significant uncertainty and time pressure. Ambulance and medical commanders should be prepared to make situation assessments and decisions early and be ready to adjust as uncertainties are reduced.

Developing templates for uniform data documentation and reporting in critical care using a modified nominal group technique

BackgroundClinical practice in trauma and critical care is predominantly derived from quantitative observational cohort studies based on data retrospectively collected from medical records. Such data create uncontrolled bias and influence external and internal validity, thereby hindering systematic reviews. Templates or standards for uniform documenting and scientific reporting may result in high quality and internationally standardised data being collected on a regular basis, enhance large international multi-centre studies, and increase the quality of evidence. Templates or standards may be developed using multidisciplinary expert panel consensus methods.We present three consensus processes aimed at developing templates for documenting and scientific reporting. We discuss the advantages, limitations, and possible future improvements of our method.MethodsThe template preparation was based on expert panel consensus derived through a modified nominal group technique (NGT) method that combined the traditional Delphi method with the traditional NGT method in a four-step process.ResultsStandard templates for documenting and scientific reporting were developed for major trauma, pre-hospital advanced airway handling, and physician-staffed pre-hospital EMS. All templates were published in scientific journals.ConclusionOur modified NGT consensus method can successfully be used to establish templates for reporting trauma and critical care data. When used in a structured manner, the method uses recognised experts to achieve consensus, but based on our experiences, we recommend the consensus process to be followed by feasibility, reliability, and validity testing.

Percutanous dilatational tracheotomy in the ICU: a Norwegian survey focusing on perceived risk and safety attitudes

Background and objectives: Despite its popularity, serious complications do occur with percutaneous dilatational tracheotomy in the ICU. The associated risks in daily practice are probably underestimated and may reflect system flaws in training and team function. This study was performed to obtain an impression of risk perception and safety culture in connection with percutaneous dilatational tracheotomy in Norwegian ICUs. Methods: The Medical Director or intensivist on‐call in the 30 ICUs participating in the Norwegian Intensive Care Registry was telephone interviewed using a semi‐structured questionnaire. Data on the practice of tracheotomy and a qualitative assessment of complications experienced during the last 2 years were collected. In the second part, percutaneous dilatational tracheotomy operators in two ICUs were questioned about their perception of risk with percutaneous dilatational tracheotomy and asked to assess their own abilities as percutaneous dilatational tracheotomy operators and the training they had undergone. Results: Of the 30 ICUs, 23 used percutaneous dilatational tracheotomy. The majority reported knowledge of severe complications like bleeding, hypoxia and tube dislodgment. Percutaneous dilatational tracheotomy‐related deaths were also reported. Operators rated themselves relatively low and indicated the absence of any organized training. They acknowledged the known hazards related to percutaneous dilatational tracheotomy and suggested measures like fibreoptic guidance during the percutaneous dilatational tracheotomy and fewer operators with more experience as well as better team training, to improve patient safety. Conclusion: Based on the frequent reporting of serious complications and the suggested safety precautions, we conclude that the percutaneous dilatational tracheotomy is considered a high‐risk procedure and that there is still room for improving the safety of this much used ICU procedure.

Simulation-based training and assessment of non-technical skills in the Norwegian Helicopter Emergency Medical Services: a cross-sectional survey

Background Human error and deficient non-technical skills (NTSs) among providers of ALS in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. Objective To document the current level of simulation-based training and assessment of seven generic NTSs in crew members in the Norwegian HEMS. Methods A cross-sectional survey, either electronic or paper-based, of all 207 physicians, HEMS crew members (HCMs) and pilots working in the civilian Norwegian HEMS (11 bases), between 8 May and 25 July 2012. Results The response rate was 82% (n=193). A large proportion of each of the professional groups lacked simulation-based training and assessment of their NTSs. Compared with pilots and HCMs, physicians undergo statistically significantly less frequent simulation-based training and assessment of their NTSs. Fifty out of 82 (61%) physicians were on call for more than 72 consecutive hours on a regular basis. Of these, 79% did not have any training in coping with fatigue. In contrast, 72 out of 73 (99%) pilots and HCMs were on call for more than 3 days in a row. Of these, 54% did not have any training in coping with fatigue. Conclusions Our study indicates a lack of simulation-based training and assessment. Pilots and HCMs train and are assessed more frequently than physicians. All professional groups are on call for extended hours, but receive limited training in how to cope with fatigue.