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Rock and Fluid data provide critical input parameters for reservoir characterisation, production, and reserve forecasts. These datasets are key building blocks for reservoir simulation models, but there has been limited work in the oil industry on the standardisation of their data structures, formats, or quality control. We will present experiences and results from an ongoing digitalisation initiative. This initiative centres on establishing a database that includes all relevant analysis done on rock and fluid data. The database currently has thousands of wells covering over a hundred NCS fields that can be easily accessed via standard interfaces. As the data are contextualised on e.g., lithostratigraphic units, end-users can analyze data by groups, formation, geological time, and depositional environment. A key challenge for rock and fluid data compared to simpler oil industry datasets, is that one discipline's analysis and modelling results represent another discipline's input data. We will present an approach to resolve these challenges and discuss how this relates to ongoing joint standardisation efforts in the industry such as the OSDU Forum. In this paper we will show how industrial DataOps technology and close collaboration between domain experts, data managers and technologists has unlocked great value based on Rock and Fluid data. We will describe the workflow of finding and verifying data, establishing standard formats, implementing automated data validation and ingestion, and how we manage, visualise, and interpret data, ensure full data integrity, and make data available for end-users through different applications. We will provide examples on how machine learning can be used for automated trend analysis and identification of relationships across different data types to support model generation. Finally, we will demonstrate a state of the art and seamless workflow of generating static and dynamic SCAL model input for reservoir simulation with uncertainty band. This includes evaluation and verification of both static and dynamic SCAL data. Relative permeability and capillary pressure curves from each laboratory experiment are quality assured, parameterised and stored in the database, along with all relevant information such as plug properties, well name, fluid properties, experimental conditions, flow parameters and endpoint saturations etc.

The study examined sleep and sleepiness among shift working Helicopter Emergency Medical Service pilots from Norway (Norwegian Air Ambulance; NAA) and Austria (Christophorus Flugrettungverein; CFV). Both pilot groups (N = 47) worked seven consecutive 24 h shifts. Sleep was assessed by diaries and actigraphy while sleepiness was assessed by the Karolinska Sleepiness Scale, all administered throughout the workweek. The results indicated that all pilots had later bedtime (p < 0.05) and wake-up time (p < 0.01) as they approached the workweek end, but no change during the workweek was evident regarding wake after sleep onset, time in bed, total sleep time, or sleep efficiency. The NAA pilots had later bedtime (p < 0.001) and wake-up time (p < 0.001), spent more time awake after sleep onset (p < 0.001), more time in bed (p < 0.001), slept longer (p < 0.01), and had lower sleep efficiency (p < 0.001) compared with the CFV pilots. The sleepiness levels of all pilots were slightly elevated on the first workday but lower on the following workdays (day 2p < 0.001, day 3p < 0.05). For both pilot groups, no major change in sleep or sleepiness parameters throughout the workweek was detected. The NAA pilots reported somewhat more disturbed sleep but obtained more sleep compared with the CFV pilots.

Even in tectonically inactive areas/times, the vertical motions of the Earth's interior may be significant due to glaciation. The most recent ice age massively changed the surface of northern Europe, leading to isostatic re-equilibration. We quantify the vertical motions resulting from three glacial-related mass redistribution mechanisms using, as an example, the North Sea throughout the Quaternary: (1) ice-sheet loading, (2) erosion, including glacial carving of fjords; (3) and sediment deposition. These processes yielded up to 1 km of vertical displacement of the lithosphere across the North Sea, and the corresponding sediment-tilting changed the geometry of petroleum systems and hydrocarbon migration routes. Using the Base Cretaceous Unconformity as a top seal proxy, we analyse the consequences in the Norwegian North Sea. Comparing well data to models, we suggest that tilting the Troll Field back towards its early Quaternary position flattens the palaeo-oil–water contact (palaeo-OWC), which today is tilted by up to 70 m. The Johan Sverdrup Field shows a more complex history. Hints of a palaeo-OWC tilted can be seen in permeable reservoirs, whereas deeper sporadic oil shows cannot be explained by simple tilt models. Our study illustrates how glacial-related processes may influence the development of giant oil and gas accumulations.

Source at https://doi.org/10.1080/02813432.2019.1608056. Background: Despite the potential benefits of physician-staffed Helicopter Emergency Medical Service (HEMS), many dispatches to primary HEMS missions in Norway are cancelled before patient encounter. Information is sparse regarding the health consequences when medically indicated HEMS missions are cancelled and the patients are treated by a GP and ambulance staff only. We aimed to estimate the potential loss of life years for patients in these situations. Method: We included all HEMS requests in the period 2010–2013 from Sogn and Fjordane County that were medically indicated but subsequently cancelled. This provided a selection of patients, with the purpose of studying cancellations independently of the patient’s medical status A multidisciplinary expert panel retrospectively assessed each patient’s potential loss of life years due to the lack of helicopter transport and intervention by a HEMS physician. Results: The study included 184 patients from 176 missions. Because of unavailable HEMS, seven patients (4%) were anticipated to have lost a total of 18 life years. Three patients suffered from myocardial infarction, three from stroke and one from abdominal haemorrhage. The main contribution from HEMS care in these seven cases might have been rapid transport to definitive care. The probability of a patient losing life years when in need of HEMS evacuation was found to be 0.2%. Conclusion: During the four years period seven patients lost 18 life years. Lack of rapid transport seems to be the primary cause of lost life years in this specific geographical area. Key Points Knowledge about to what extent HEMS contributes to an increased survival and a better outcome for patients is limited. Compared to similar studies on life years gained the estimated loss of life years was minor when HEMS evacuation was unavailable in this rural area. The findings indicates that lack of rapid HEMS transport was the primary cause of the estimated loss of life years.

Background Until autumn 2018 the GPs in Bergen Municipality did not attend emergency patients outside the emergency primary care centre. The ambulance staff handled emergencies on their own or were assisted by an anaesthesiologist from the helicopter emergency medical service (HEMS). The aim of this study was to investigate procedures performed by the HEMS anaesthesiologist and to assess the level of skills needed to perform these procedures. Methods This study was a retrospective assessment of data from the period 2011 to 2013 on all emergency missions in which patients were dealt with by HEMS, using a rapid-response car in Bergen Municipality. All emergency missions were sorted into three categories: No intervention, Basic or Advanced intervention. This list was made by a research group with anaesthesiologists working for Bergen HEMS and GPs with OOH experience. The list is based on curriculum found in acute medicine courses. Results HEMS responded to 716 (2.3%) out of a total of 31,696 emergencies in Bergen Municipality during the three years. In more than two-thirds (71%) of these missions, no intervention or only a basic intervention was performed. Most advanced procedures were performed in patients with cardiac arrest. Conclusion By retrospective evaluation of HEMS missions by car in Bergen municipality, we found that nearly one-third of the patients received advanced procedures. Cardiac arrest was the medical condition in which the most advanced procedures were performed. More research is needed to evaluate procedures and the importance of clinical evaluation and physicians’ experience in treating these patient groups. KEY POINTS Both HEMS and on-call GPs are needed in emergency care, and more knowledge will be useful to highlight the level of practical skills needed in these missions. There is a need for better prioritization of when to use HEMS resources and when to use on-call GPs in emergency missions. More than two-thirds of the patients involved in emergency missions received no intervention or just a basic intervention when dealt with by HEMS. This raises the issue of whether an on-call GP could have adequately treated many of the patients in this study in terms of practical skills. publishedVersion

The present study aimed to investigate the effects of shift work on sleep among pilots and Helicopter Emergency Medical Service crew members (HCM) in the Norwegian Air Ambulance. Sleep was assessed by diaries and actigraphy during a workweek (24 h duty for 7 consecutive days) in the winter season and a workweek during the summer season in pilots and HCM (N = 50). Additionally, differences in sleep were studied between the week before work, the workweek, and the week after work in both seasons. Results indicated that bedtime was later (p

BackgroundOrganizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district.MethodsAll primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable.ResultsWe included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 andp = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km,p ConclusionAfter relocating nine local OOH services into one large inter-municipal OOH district, we found no increase in requests for HEMS.

BACKGROUND AND PURPOSE 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). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on-call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter-rater agreement between the pre- and in-hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter-rater agreement was analyzed with Cohen's kappa. RESULTS Fifty-one cerebral CT scans from the MSU were included. Inter-rater agreement between prehospital anesthesiologists and the in-hospital on-call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.

Objective We compared subjectively reported sleepiness and fatigue as well as causes and management strategies for combating sleepiness among pilots working in 2 different helicopter emergency medical services operating with different shift systems. Methods Pilots from the Norwegian Air Ambulance (NAA) and Christophorus Flugrettungsverein (CFV) in Austria participated. NAA performs flight missions 24/7, whereas at the time of the study the participating CFV bases did not fly after sunset. The pilots are on duty for 1 week in both services. NAA and CFV used an identical research protocol, including questionnaires about sleep, sleepiness (Epworth Sleepiness Scale and Karolinska Sleepiness Scale), coping strategies, and work-related causes of fatigue. Results CFV pilots kept busy, whereas NAA pilots slept and did physical exercise as strategies to prevent sleepiness. The majority in both groups used napping and coffee consumption as strategies. CFV pilots reported more frequently than NAA pilots that administrative duties and environmental factors were reasons preventing napping. Conclusion Some differences existed between the 2 pilot groups regarding strategies for managing sleepiness and causes that prevented pilots from napping. Pilots in both groups were healthy, physically active, and had normal Epworth Sleepiness Scale and Karolinska Sleepiness Scale scores.

Supplemental Digital Content is available in the text., Background Cerebral revascularization in acute stroke requires robust diagnostic tools close to symptom onset. The quantitative National Institute of Health Stroke Scale (NIHSS) is widely used in-hospital, whereas shorter and less specific stroke scales are used in the prehospital field. This study explored the accuracy and potential clinical benefit of using NIHSS prehospitally. Patients and methods Thirteen anesthesiologists trained in prehospital critical care enrolled patients with suspected acute stroke in a mobile stroke unit. NIHSS was completed twice in the acute phase: first prehospitally and then by an on-call resident neurologist at the receiving hospital. The agreement between prehospital and in-hospital NIHSS scores was assessed by a Bland–Altman plot, and inter-rater agreement for predefined clinical categories was tested using Cohen’s κ. Results This Norwegian Acute Stroke Prehospital Project study included 40 patients for analyses. The mean numerical difference between prehospital and in-hospital NIHSS scores was 0.85, with corresponding limits of agreement from − 5.94 to 7.64. Inter-rater agreement (κ) for the corresponding clinical categories was 0.38. A prehospital diagnostic workup (NIHSS and computed tomographic examination) was completed in median (quartiles) 10 min (range: 7–14 min). Time between the prehospital and in-hospital NIHSS scores was median (quartiles) 40 min (32–48 min). Conclusion Critical care physicians in a mobile stroke unit may use the NIHSS as a clinical tool in the assessment of patients experiencing acute stroke. The disagreement in NIHSS scores was mainly for very low values and would not have changed the handling of the patients.

Purpose: To examine the effects of shift work and extended working hours on sleepiness among pilots and Helicopter Emergency Medical Service (HEMS) crew members in the Norwegian Air Ambulance. Methods: This field study investigated sleepiness during 3 consecutive weeks: the week before work, the work week, and the week after work. The pilots and HEMS crew members (N = 50) kept a wake diary during all 3 weeks and completed reaction time tests during the work week. Results: The overall sleepiness scores were low during all 3 weeks. When comparing the 3 weeks, the lowest sleepiness levels were found for the work week. There was a small difference across work days, in which subjective sleepiness scores were highest the first duty day. No change in the reaction time tests was evident during the work week. The crew members reported being most sleepy at midnight, compared to all the other timepoints over the course of a duty day. Regarding workload and total work time, having larger workload was associated with lower sleepiness scores, while having higher total work time was associated with higher sleepiness score, both compared to the medium category. Conclusions: The findings indicate that the work schedules and setting for this distinct occupational group do not seem to negatively affect the sleepiness levels. publishedVersion

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. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Aim Over the last decades out-of-hour services in Norway have been centralised to cover lager geographical areas, resulting in longer response times for the on-call GP. Reports indicate an unintended increase in requests of helicopter emergency medical services (HEMS) as a result. We aimed to investigate alteration in the requests for HEMS and NACA-score of the patients transported. Method In 2009 nine municipalities in the county of Sogn og Fjordane relocated all local out-of-hour services into one large casualty clinic (SYS-IKL). We included all primary HEMS requests in the county from 2004–2013 and compared missions within the area of SYS-IKL to missions in the rest of the county. Results Preliminary data included 7310 requests. Within SYS-IKL requests were 4.4 per week in the period. Completed and cancelled requests were 3.0 and 1.3 per week before 2009 compared to 2.7 and 1.6 per week after 2009. Outside SYS-IKL requests were 8.9 per week before 2009 and 10.4 per week after 2009. Completed and cancelled requests were 5.1 and 3.4 per week before 2009 compared to 5.5 and 4.6 per week after 2009. Mean NACA-score within SYS-IKL was 3.98 and 3.87 (p=0.115) compared to 3.78 and 3.77 (p=0,786) outside SYS-IKL before and after 2009, respectively. Conclusion Preliminary results did not confirm the hypothesised increase in use of HEMS or reduced NACA-score due to centralization of out-of-hour services. However, further statistical analyses are required. Conflict of interest None Funding Norwegian Air Ambulance Foundation.

Background: Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data. Methods: We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5-95 percentile) of 4675 (940-36,264) inhabitants and 10 (2-38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure. Results: The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was -0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts. Conclusion: Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Source at https://doi.org/10.1111/aas.13032. Background: Rapid and precise dispatch of resources is a key element in pre‐hospital emergency medicine. Emergency medical communication centres (EMCCs) dispatch resources based on protocols and guidelines, balancing the acute need of the individual and the resource allocation of the pre‐hospital emergency medical system. The aim of this study was to determine the validity of stroke identification by the Norwegian dispatch guidelines. Method and material: This was a register‐based study where patients suspected for stroke were compared to those with the final diagnosis of stroke as an indicator group for the guideline validation. One EMCC and its three associated hospitals participated with 13 months of data. Four subcodes of the stroke dispatch code were defined as suspicious of stroke and further analysed. Factors associated with stroke identification were explored. Results: The sensitivity for identifying a stroke patient at initial EMCC contact was 57.9% (51.5, 64.1), specificity was 99.1% (98.9, 99.2), positive predictive value was 45.7% (40.1, 51.4) and negative predictive value was 99.4% (99.3, 99.5). The emergency medical access telephone (113) was initial EMCC contact line in only 48% of the cases. Paralyses and admittance to a smaller hospital were associated with increased probability for stroke (OR 2.6, P = 0.001 and OR 2.7, P = 0.01), respectively. Conclusion The sensitivity for identification of stroke patients by the dispatch guidelines is modest, while the specificity is high. The 113 telephone line was initial EMCC access point for less than half of the stroke patients.

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 government's 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. Helicopter emergency medical services (HEMS) are an integral part in many health care systems in the developed world. The effect of HEMS is still subject to debate although they have several theoretical advantages, such as bringing advanced medical care and medical competence to the scene, shortening the transport time, providing access to remote areas, and reducing the time elapsed until definitive care is available. Several outcome studies have found positive associations with increased survival under the care of HEMS, whereas the opposite effects have also been well documented. However, many of these studies have been subject to methodological limitations, selection bias, and noncomparable study settings or designs. A position paper by several American air medical societies initiated the process of establishing national guidelines to facilitate the beneficial effects of HEMS implementation. The paper stated that clinical benefit could be provided by minimizing the time to definitive care in time-sensitive medical conditions, providing necessary competence and equipment on the scene, and accessing patients who are otherwise inaccessible by other modes of transport.4 These objectives are consistent with national guidelines in other countries. Based on international experiences, a Norwegian national air ambulance (AA) service was established in 1988. A paramount principle in Norwegian health legislation is that all citizens should have equal access to publicly funded health care regardless of their residential pattern. In that sense, well-developed air emergency services have a compensatory effect that adjusts for geographic dispersion and potential unequal access to advanced emergency medical care. A time frame of 45 minutes, including up to a 15-minute reaction time from alarm to takeoff, has been defined as the national goal to reach 90% of the population. In 2002, Heggestad and Børsheim published results on the accessibility and distribution of the Norwegian national air emergency service. In their study, the mean reaction time was 8 minutes in acute missions (from alarm until takeoff), and the mean total response time from alarm until scene arrival was 26 minutes. Nearly 98% of the population was reached within 60 minutes. Within the last decade, the population has increased, enhanced medical capabilities have been developed, and additional helicopter bases have been implemented. Hence, the aims of this study were to document the accurate flying times of rotor wing units to the scene as well as the rates of acute primary missions in Norway. publishedVersion

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 patient’s medical condition that was critical for the doctor’s 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 patient’s 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 patient’s needs and what was practically possible for the doctor. The out-of-hours doctors experienced a need for medical

BACKGROUND AND PURPOSE 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). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on‐call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter‐rater agreement between the pre‐ and in‐hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter‐rater agreement was analyzed with Cohen's kappa. RESULTS Fifty‐one cerebral CT scans from the MSU were included. Inter‐rater agreement between prehospital anesthesiologists and the in‐hospital on‐call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.

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.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.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 patient's medical condition that was critical for the doctor's 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 patient's need for medical expertise was the most important reason given.In the incidents studied, the decision on whether or not to respond with a call-out was based on a balanced consideration of the patient's 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.

Background and purpose 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. Methods Thirteen anaesthesiologists attended an 8-h course in acute stroke assessment, including a 2-h introduction to the neuroradiology of acute stroke. Each participant then assessed 12 non-contrast cerebral CT examinations of acute stroke patients with specific regard to radiological contraindications for thrombolytic therapy. Test results were compared with those of three experienced neuroradiologists. Inter-rater agreement between anaesthesiologists and neuroradiologists was calculated using Cohen's Kappa statistics. Robustness of the results was assessed using the non-parametric bootstrap. Results Among the neuroradiologists, Kappa was 1 for detecting radiological contraindications for thrombolytic therapy. Twelve of the 13 anaesthesiologists showed good or excellent agreement (Kappa > 0.60) with the neuroradiologists. The anaesthesiologists spent a median time of 2 min and 18 s on each CT scan. Conclusions This study suggests that anaesthesiologists who are experienced in pre-hospital care may be quickly trained to assess cerebral CT examinations in acute stroke patients with regard to radiological contraindications for thrombolytic therapy.

Background Chest pain is a common diagnostic challenge in primary care and diagnostic measures are often aimed at confirming or ruling out acute ischaemic heart disease. The aim of this study was to investigate management of patients with chest pain out-of-hours, including the use of ECG and laboratory tests, assessment of severity of illness, and the physicians’ decisions on treatment and admittance to hospital. Methods Data 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. Results A total of 832 patients with chest pain were registered. The first 100 patients (corresponding doctor-patient pairs) were included in the study according to the predefined inclusion criteria. Median age of included patients was 46 years, men constituted 58%. An ECG was taken in 92 of the patients. Of the 24 patients categorised to acute level of response, 15 had a NACA-score indicating a potentially or definitely life-threatening medical situation. 50 of the patients were admitted to a hospital for further management, of which 43 were thought to have ischaemic heart disease. Musculoskeletal pain was the second most common cause of pain (n = 22). Otherwise the patients were thought to have a variety of conditions, most of them managed at a primary care level. Conclusions Patients with chest pain presenting at out-of-hours services in Norway are investigated for acute heart disease, but less than half are admitted to hospital for probable acute coronary syndrome, and only a minority is given emergency treatment for acute coronary syndrome. A wide variety of other diagnoses are suggested by the doctors for patients presenting with chest pain. Deciding the appropriate level of response for such patients is a difficult task, and both over- and under-triage probably occur in out-of-hours primary care.

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 group's 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 group's procedures and roles.

Background Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs). Methods Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response (defined as an "acute" response, with the highest priority), according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study. Results 5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a life-threatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor ("left at the scene"). Conclusions The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals.

Background Primary care doctors on-call in the emergency primary health care services in Norway are, together with the ambulances, the primary resources for handling emergencies outside hospitals. There is a lack of reliable data for Norway on how often the primary care doctors are alerted and on their responses in the most urgent emergency cases. The aim of this study was to investigate how doctors on-call are involved in red responses (highest priority), using three different emergency medical communication centres (EMCC) as catchment area for a prospective population-based study. Methods In the period from October to December 2007 three dispatch centres covering approximately 816 000 inhabitants prospectively recorded all acute emergency cases. Ambulance records, air ambulance records and records from the doctors on-call were collected. NACA score was used to define the severity of the emergencies. Results 5 105 cases were classified as red responses during the period. We have complete basic recordings (AMIS forms) from all and resaved ambulance records, air ambulance records and records from doctors on-call in 89% of the cases. Ambulances were alerted in 96% and doctors on-call in 47% of the cases, but there were large differences between the three EMCCs. Doctors on-call responded with call-out in 42% of the alerted cases. 28% of all patients were taken to a casualty clinic, 46% were admitted to hospital by a doctor and 24% were taken directly to hospital by ambulances. In total, primary care doctors on-call took active part in 42% of all red response cases, and together with GPs' daytime activity the primary health care services were involved in 50% of the cases. 29% of the cases were classified as life-threatening. Call-out by doctors on-call were found to be more frequent in life-threatening situations compared with not life-threatening situations. Conclusion Doctors on-call and GPs on daytime were involved in half of all red responses. There were large differences between the EMCCs in the frequency of doctors alerted. The inhabitants in the three EMMCs were thus offered different levels of professional competency in emergency situations outside hospitals.

Introduction There is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway. Method Three emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively. Results Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age. Conclusions The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.

Background In Norway, no valid activity statistics from the primary health care out-of-hours services or the pre-hospital emergency health care system have previously been available. Methods The National Centre for Emergency Primary Health Care has initiated an enterprise called "The Watchtowers" which consists of a representative sample of seven casualty clinics covering 18 Norwegian municipalities. The purpose of the project is to provide routine information over several years, which will enable monitoring, evaluation and comparison of the activities in the out-of-hours services. This paper presents data from 2007, the first full calendar year for the Watchtowers, analyzes some differences in user patterns for the seven casualty clinics involved, and estimates national figures for the use of casualty clinics and out-of-hours services in Norway. Results A total of 85 288 contacts were recorded during 2007 [399 per 1 000 inhabitants] of which 64 846 contacts were considered non-urgent [76.6%]. There were 53 467 consultations by a doctor [250 per 1 000], 8 073 telephone consultations by doctor [38 per 1 000], 2 783 home visits and call-outs by doctor [13 per 1000] and 20 502 contacts managed by nurses on their own [96 per 1000]. The most common mode of contact was by telephone. Women, young children and elderly had the highest rates of contact. Conclusion Norway has a high rate of contacts to the out-of-hours services compared with some other countries with available data. Valid national figures and future research of these services are important both for local services and policy makers.

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.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.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.Ambulance personnel have strong confidence in their own occupational group's 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 group's procedures and roles.

The Norwegian Air Ambulance Foundation started a first responder defibrillator program in cooperation with the Norwegian Ministry of Health and Care Services in 2002. By January 2007, 250 half-automatic defibrillators had been made available in 200 municipalities and 250 users had been trained. The aim of the study was to identify defibrillator users' motivation, self-assessed competence and their experience with the referring physician.In autumn 2005, a structured questionnaire was sent to 490 providers (a 50% random selection of all 980) who attended the first responder defibrillator program and course in 2002/2003. The response rate was 70% (307/439).33% of the providers had not received a formal delegation certificate from a doctor. A majority (75%) of providers had not met the actual doctor and could therefore not tell if they were involved in the program. Almost everyone (99%) meant that they personally and that the first responder group as a whole (98%) would manage the job. For the 120 (39%) users who had been in a real-life situation corresponding numbers were 93% and 90%. Real-life situations had a positive effect on motivation for 71 (59%) of the first responders.This study indicates that for most doctors delegation of responsibility was a formality without any professional content. The first responders were self-confident and motivated.

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.

To study the geographic size of out-of-hours districts, the availability of defibrillators and use of the national radio network in Norway.Survey.The emergency primary healthcare system in Norway.A total of 282 host municipalities responsible for 260 out-of-hours districts.Size of out-of-hours districts, use of national radio network and access to a defibrillator in emergency situations.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.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.

Out-of-hours work is often perceived as burdensome and there is an inherent increased risk of making mistakes. The aim of the study was to examine Regular General Practitioners' (RGPs') experiences with and attitudes to out-of-hours work.A questionnaire was sent to all RGPs in Norway. Participation in out-of-hours work was analysed against characteristics of the physician, list, and municipality.2,913 RGPs responded (78%). 50% participated fully, 15% partly, and 35% did not participate in out-of-hours work. 28% were formally exempted, and 13% had a regular locum. Women and elderly RGPs participated less, as did RGPs in large and central municipalities. Out-of-hours cooperatives covering several municipalities reduced the amount of work, but did not increase the RGPs' participation rate. List characteristics had little influence on the participation rate. 60% of the RGPs tried to give away most of their duties, 16% wanted more out-of-hours work than their regular duties and 16% of those below 55 years who were still doing out-of-hours work wanted to continue after 55 years. RGPs in small and remote municipalities considered out-of-hours work more challenging, but less remunerating, and more often wanted to move from the municipality.Many RGPs do not participate in out-of-hours work. As Norwegian RGPs constitute an aging cohort, this may become an increasing problem.

Limited data are available on casualty clinic facilities and localisation, inter-municipal co-operation and routines for out-of-hours services in the 433 Norwegian municipalities. The National centre for emergency primary health care collected data on these issues from October 2005 until February 2006.Questionnaires concerning organisation of the out-of-hours services, casualty clinic facilities, locations and routines were sent to every Norwegian municipality.282 of the 433 municipalities are in charge of out-of-hours services in 262 districts in the evenings and 230 districts during nights and weekends. There is inter-municipal cooperation in 100 of the districts. Most out-of-hours services are located in one casualty clinic in the host municipality and have the same locations as GP surgeries and laboratories. Most clinics offered the same services, but some routines were different. About half of the casualty clinics had a system for training of doctors and other health personnel. Half of the doctors on duty were available on the emergency communications system (radio). User assessments were collected, telephone calls documented and discrepancies reported to a varying degree, and medical histories were not consistently sent to regular GPs.Inter-municipal co-operations are most common in areas with a high population density, i.e. in southern and eastern parts of Norway. Varying routines in out-of-hours service districts indicate that several municipalities do not fulfil all the obligations in regulations from the Ministry of health and care services in Norway.

Background The municipalities are responsible for the emergency primary health care services in Norway. These services include casualty clinics, primary doctors on-call and local emergency medical communication centres (LEMC). The National centre for emergency primary health care has initiated an enterprise called "The Watchtowers", comprising emergency primary health care districts, to provide routine information (patients' way of contact, level of urgency and first action taken by the out-of-hours services) over several years based on a minimal dataset. This will enable monitoring, evaluation and comparison of the respective activities in the emergency primary health care services. The aim of this study was to assess incidence of emergency contacts (potential life-threatening situations, red responses) to the emergency primary health care service. Methods A representative sample of Norwegian emergency primary health care districts, "The Watchtowers" recorded all contacts and first action taken during the year of 2007. All the variables were continuously registered in a data program by the attending nurses and sent by email to the National Centre for Emergency Primary Health Care at a monthly basis. Results During 2007 the Watchtowers registered 85 288 contacts, of which 1 946 (2.3%) were defined as emergency contacts (red responses), corresponding to a rate of 9 per 1 000 inhabitants per year. 65% of the instances were initiated by patient, next of kin or health personnel by calling local emergency medical communication centres or meeting directly at the casualty clinics. In 48% of the red responses, the first action taken was a call-out of doctor and ambulance. On a national basis we can estimate approximately 42 500 red responses per year in the EPH in Norway. Conclusion The emergency primary health care services constitute an important part of the emergency system in Norway. Patients call the LEMC or meet directly at casualty clinics with medical problems that initially are classified as a potentially life-threatening situation, a red response.

Purpose of the study: Automated external defibrillators (AED) can be used outside the hospitals by lay or non-healthcare providers. The goal of the study was to check, if lay rescuers can rely on the instructions while using AED and prepare it adequately. Materials and methods: The research was undertaken on a group of 100 first year Medical Faculty students of the University of Medical Sciences in Poznan. After short theoretical introduction how to use AED they were asked to demonstrate on a manikin BLS-AED procedure. Their skills were tested when they relied on the instruction belonging to the AED (500 T Lifepack). Results: We have observed some important errors, when the students were performing the AED procedure. We can classify these errors into two groups. One is connected with the attachment of the electrode pads. The second group is connected with the use of the AED. The students put AED on the opposite side to the rescuer, they continued with the vocal and visual instructions, they were touching the victim during the use of the AED and they did not decide to use the AED in pregnancy. The observed errors indicate the need to change the instructions for the use of the AED because it lacks important information. The students tested were not safe using the AED based on the instructions contained with the device. Conclusions: Based on the results, we can conclude that the instruction of the use of AED can lead to dangerous performance like not defibrillation of the victim and current shock of the rescuer. The belonging to AED instruction should be modified.