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Background: Few clinical studies investigate technical skill performance in experienced clinicians., Methods: We undertook a prospective observational study evaluating procedural skill competence in consultant anaesthetists who performed flexible bronchoscopic intubation (FBI) under continuous ventilation through a second-generation supraglottic airway device (SAD). Airway management was recorded on video and performance evaluated independently by three external assessors. We included 100 adult patients undergoing airway management by 25 anaesthetist specialists, each performing four intubations. We used an Objective Structured Assessment of Technical Skills-inspired global rating scale as primary outcome. Further, we assessed the overall pass rate (proportion of cases where the average of assessors' evaluation for every domain scored ≥3); the progression in the global rating scale score; time to intubation; self-reported procedural confidence; and pass rate from the first to the fourth airway procedure., Results: Overall median global rating scale score was 29.7 (interquartile range 26.0-32.7 [range 16.7-37.7]. At least one global rating scale domain was deemed 'not competent' (one or more domains in the evaluation was scored <3) in 30% of cases of airway management, thus the pass rate was 70% (95% CI 60%-78%). After adjusting for multiple testing, we found a statistically significant difference between the first and fourth case of airway management regarding time to intubation (p = .006), but no difference in global rating scale score (p = .018); self-reported confidence before the procedure (p = .014); or pass rate (p = .109)., Conclusion: Consultant anaesthetists had a median global rating scale score of 29.7 when using a SAD as conduit for FBI. However, despite reporting high procedural confidence, at least one global rating scale domain was deemed 'not competent' in 30% of cases, which indicates a clear potential for improvement of skill competence among professionals., (© 2023 Acta Anaesthesiologica Scandinavica Foundation.)

Background: In case of distorted airway anatomy, awake intubation with a flexible bronchoscope can be extremely difficult or even impossible. To facilitate this demanding procedure, an infrared flashing light source can be placed on the patient's neck superficial to the cricothyroid membrane. The light travels through the skin and tissue to the trachea, from where it can be registered by the advancing bronchoscope in the pharynx and seen as flashing white light on the monitor. We hypothesised that the application of this technique would allow more proximal and easier identification of the correct pathway to the trachea in patients with severe airway pathology., Methods: As part of awake intubation, patients underwent insertion of a flexible video bronchoscope via the mouth into the trachea. The procedure was performed twice, in random order in each patient, with and without the aid of the transcutaneous flashing infrared light. All insertions were video recorded to determine at which anatomical landmark within the airway the correct pathway was identified. The videos are accessible via this link: https://airwaymanagement.dk/infrared&#95;comparative. The predefined landmarks were in successive order: oral cavity, oro-pharynx, tip of epiglottis, arytenoid cartilages, false cords, vocal cords and trachea, as well as the spaces between them., Results: Twenty-two patients had a total of 44 awake insertions with the flexible bronchoscope. The median anatomical level, at which correct identification of the trachea was obtained on the monitor, was, past the epiglottis, with the conventional technique, and at the level of the oropharynx, when using the infrared flashing light (p = .005). The time until the flashing light or the vocal cords were seen was 21 (22) S, mean (SD), and 48 (62) S, during the insertion with and without infrared flashing light activated, respectively (p = .005). Endoscopists rated it easier (p = .001) to recognise the entrance to the trachea in the infrared-group., Conclusion: During awake intubation of patients with airway pathology, the application of trans-cricothyroid infrared flashing light to guide the insertion of a flexible bronchoscope significantly facilitated the recognition of the pathway into the trachea and the correct advancement of the flexible endoscope., Registration of Clinical Trial: NCT03930550., (© 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Objectives: To report on the safety and efficacy of transvenous cardiac pacing wire insertion outside a tertiary hospital by a medical retrieval service., Methods: SAAS MedSTAR Emergency Medical Retrieval Service transports symptomatic bradycardic patients in rural South Australia to Adelaide on transvenous pacing for ongoing management. This is a retrospective case review of all transvenous cardiac pacing wires inserted by SAAS MedSTAR between January 2015 and October 2017., Results: This study demonstrated successful insertion of cardiac transvenous pacing wires and cardiac capture in 10 of 11 cases (91%) by pre-hospital and retrieval doctors. There were no immediate or long-term complications from insertion. All of the patients were successfully transferred by helicopter or fixed wing to their receiving facility, with nine of the 11 patients (82%) surviving to hospital discharge., Conclusion: This paper demonstrates that transvenous cardiac pacing can be safely and successfully implemented for symptomatic patients by pre-hospital and retrieval physicians in the aeromedical retrieval setting., (© 2019 Australasian College for Emergency Medicine.)

Introduction: Implementation of a physician-staffed helicopter emergency medical service (HEMS) in eastern Denmark was associated with increased survival for severely injured patients. This study aimed to assess the potential impact of advanced prehospital interventions by comparing the proportion of patients who received those interventions before and after the HEMS implementation., Methods: A post-hoc analysis of a prospective before-after study. We included trauma patients with Injury Severity Scores above three who had been admitted to seven emergency departments or one level 1 trauma centre in the course of a five-month period before and a 12-month period after the HEMS implementation. We compared the proportion of patients receiving at least one of 14 predefined advanced interventions between the two periods., Results: We included 189 patients before and 548 patients after the implementation. The proportion of patients who had interventions done increased from 24.3% to 36.1% (difference (95% confidence limits (CL)): 11.9% (4.6-19.3%); p = 0.003). In patients with a Glasgow Coma Scale score below nine and/or an Abbreviated Injury Score above three in the head region, endotracheal intubation was done prior to hospital arrival in 28.1% (9/32) before versus 48.6% (35/72) after (difference (CL): 20.5% (1.1-39.9%)). The proportion of patients who received opioids increased from 11.1% to 21.8% (p < 0.01)., Conclusions: A higher proportion of trauma patients received advanced prehospital interventions after the implementation of a physician-staffed HEMS., Funding: Funding for this study was received from TrygFonden., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Background: Transportation by helicopter may reduce time to hospital admission and improve outcome. We aimed to investigate the effect of transport mode on mortality, disability, and labour market affiliation in patients admitted to the stroke unit., Methods: Prospective, observational study with 5.5 years of follow-up. We included patients admitted to the stroke unit the first three years after implementation of a helicopter emergency medical services (HEMS) from a geographical area covered by both the HEMS and the ground emergency medical services (GEMS). HEMS patients were compared with GEMS patients. Primary outcome was long-term mortality after admission to the stroke unit., Results: Of the 1679 patients admitted to the stroke unit, 1068 were eligible for inclusion. Mortality rates were 9.04 per 100 person-years at risk (PYR) in GEMS patients and 9.71 per 100 PYR in HEMS patients (IRR = 1.09, 95% CI 0.79-1.49; p = 0.60). The 30-day mortality was 7.4% with GEMS and 7.9% with HEMS (OR = 1.02, CI 0.53-1.96; p = 0.96). Incidence rate of involuntary early retirement was 6.97 per 100 PYR and 7.58 per 100 PYR in GEMS and HEMS patients, respectively (IRR = 1.19, CI 0.27-5.26; p = 0.81). Work ability after 2 years and time on social transfer payments did not differ between groups. We found no significant difference in mean modified Rankin Scale score after 3 months (2.21 GEMS vs. 2.09 HEMS; adjusted mean difference = -0.20, CI -0.74-0.33; p = 0.46)., Discussion: The possible benefit of HEMS for neurological outcome is probably difficult to detect by considering mortality, but for the secondary analyses we had less statistical power as illustrated by the wide confidence intervals., Conclusion: Helicopter transport of stroke patients was not associated with reduced mortality or disability, nor improved labour market affiliation compared to patients transported by a ground unit., Trial Registration: The study was registered at ClinicalTrials.gov ( NCT02576379 ).

Background: Advances in technology have made ultrasound (US) devices smaller and portable, hence accessible for prehospital care providers. This study aims to evaluate the effect of a four-hour, hands-on US training course for physicians working in the prehospital setting. The primary outcome measure was US performance assessed by the total score in a modified version of the Objective Structured Assessment of Ultrasound Skills scale (mOSAUS)., Methods: Prehospital physicians participated in a four-hour US course consisting of both hands-on training and e-learning including a pre- and a post-learning test. Prior to the hands-on training a pre-training test was applied comprising of five videos in which the participants should identify pathology and a five-minute US examination of a healthy volunteer portraying to be a shocked patient after a blunt torso trauma. Following the pre-training test, the participants received a four-hour, hands-on US training course which was concluded with a post-training test. The US examinations and screen output from the US equipment were recorded for subsequent assessment. Two blinded raters assessed the videos using the mOSAUS., Results: Forty participants completed the study. A significant improvement was identified in e-learning performance and US performance, (37.5 (SD: 10.0)) vs. (51.3 (SD: 5.9) p = < 0.0001), total US performance score (15.3 (IQR: 12.0-17.5) vs. 17.5 (IQR: 14.5-21.0), p = < 0.0001) and in each of the five assessment elements of the mOSAUS., Conclusion: In the prehospital physicians assessed, we found significant improvements in the ability to perform US examinations after completing a four-hour, hands-on US training course.

Objectives: System delay (time from first medical contact to primary percutaneous coronary intervention) is associated with heart failure and mortality in patients with ST segment elevation myocardial infarction (STEMI). We evaluated the impact of system delay on left ventricular function (LVF) according to the combination of ischemia severity (Sclarovsky-Birnbaum grades) and acuteness (Anderson-Wilkins scores) in the pre-hospital electrocardiogram (ECG)., Methods: In a predefined secondary analysis of a prospective study, the severity and acuteness scores were performed on the pre-hospital ECG. Patients were assessed with respect to 4 classifications which were not mutually exclusive: severe ischemia (+SI) or non-severe ischemia (-SI) and acute ischemia (+AI) or non-acute ischemia (-AI). LVF was assessed by global longitudinal strain (GLS) within 48hours of admission. Adjusted linear regression investigated the association of system delay with GLS in each group., Results: In total 262 patients were eligible for analysis of the ECG, which resulted in 42 (16%) with (+SI, -AI), 110 (42%) with (-SI, -AI), 90 (34%) with (-SI, +AI), and 20 (8%) patients with (+SI, +AI). Although system delay did not differ between groups, patients with severe and non-acute ischemia had the most impaired LVF. System delay correlated weakly with GLS in the entire population (r=0.133, p=0.031), and well with GLS in the (+SI, +AI) group (r=0.456, p=0.04), while there was no correlation in the other groups. By adjusted analysis, system delay predicted impaired GLS only in the (+SI, +AI) group (β=0.578, p=0.002)., Conclusion: Pre-hospital risk stratification by ECG identifies patients with acute and severe ischemia who are at increased risk for reduced ventricular function (assessed by GLS) after STEMI. Optimizing reperfusion delays in these patients can therefore be of particular benefit in improving clinical outcome after STEMI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The first Danish Helicopter Emergency Medical Service (HEMS) was introduced May 1st 2010. The implementation was associated with lower 30-day mortality in severely injured patients. The aim of this study was to assess the long-term effects of HEMS on labour market affiliation and mortality of trauma patients., Methods: Prospective, observational study with a maximum follow-up time of 4.5 years. Trauma patients from a 5-month period prior to the implementation of HEMS (pre-HEMS) were compared with patients from the first 12 months after implementation (post-HEMS). All analyses were adjusted for sex, age and Injury Severity Score., Results: Of the total 1994 patients, 1790 were eligible for mortality analyses and 1172 (n=297 pre-HEMS and n=875 post-HEMS) for labour market analyses. Incidence rates of involuntary early retirement or death were 2.40 per 100 person-years pre-HEMS and 2.00 post-HEMS; corresponding to a hazard ratio (HR) of 0.72 (95% confidence interval (CI) 0.44-1.17; p=0.18). The HR of involuntary early retirement was 0.79 (95% CI 0.44-1.43; p=0.43). The prevalence of reduced work ability after three years were 21.4% vs. 17.7%, odds ratio (OR)=0.78 (CI 0.53-1.14; p=0.20). The proportions of patients on social transfer payments at least half the time during the three-year period were 30.5% vs. 23.4%, OR=0.68 (CI 0.49-0.96; p=0.03). HR for mortality was 0.92 (CI 0.62-1.35; p=0.66)., Conclusions: The implementation of HEMS was associated with a significant reduction in time on social transfer payments. No significant differences were found in involuntary early retirement rate, long-term mortality, or work ability., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Mortality may be higher for admissions at odd hours than during daytime, although for trauma patients results are conflicting. The objective of this study was to assess whether diurnal differences in mortality among severely injured trauma patients in Denmark were present., Methods: This observational cohort study was conducted between 1 December 2009 and 30 April 2011 involving one level 1 trauma centre and seven local emergency departments in eastern Denmark. Patients were consecutively included if received by a designated trauma team. Night-time patients (20:00-07:59) were compared with daytime patients (20:00-07:59). An injury severity score (ISS) >15 defined severe injury. Patients with burns and patients who upon arrival were declared non-trauma patients were not included. The primary outcome measure was 30-day mortality., Results: A total of 1985 patients were recorded, of whom 576 were admitted at night-time, 1369 at daytime and 40 not included due to missing data. There were 142 patients with ISS >15 in the daytime group and 64 at night-time. The 30-day mortality was 14.1% for admittance at night-time versus 21.3% at daytime (p=0.22). Logistic regression analysis revealed that odd-hour admission was not a significant predictor of mortality for patients with ISS >15 when adjusted for age, ISS and initial treatment facility (OR 0.71 (95% CI 0.27 to 1.90); p=0.50)., Conclusions: In conclusion, we found no diurnal differences in 30-day mortality for severely injured trauma patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Helicopters are widely used for interhospital transfers of stroke patients, but the benefit is sparsely documented. We hypothesised that helicopter transport would reduce system delay to thrombolytic treatment at the regional stroke centre., Methods: In this prospective controlled observational study, we included patients referred to a stroke centre if their ground transport time exceeded 30 min, or they were transported by a secondarily dispatched, physician-staffed helicopter. The primary endpoint was time from telephone contact to triaging neurologist to arrival in the stroke centre. Secondary endpoints included modified Rankin Scale at 3 months, 30-day and 1-year mortality., Results: A total of 330 patients were included; 265 with ground transport and 65 with helicopter, of which 87 (33%) and 22 (34%), received thrombolysis, respectively (p=0.88). Time from contact to triaging neurologist to arrival in the regional stroke centre was significantly shorter in the ground group (55 (34-85) vs 68 (40-85) min, p<0.01). The distance from scene to stroke centre was shorter in the ground group (67 (42-136) km) than in the helicopter group (83 (46-143) km) (p<0.01). We did not detect significant differences in modified Rankin Scale at 3 months, in 30-day (9.4% vs 0%; p=0.20) nor 1-year (18.8% vs 13.6%; p=0.76) mortality between ground and helicopter transport., Conclusions: We found significantly shorter time from contact to triaging neurologist to arrival in the regional stroke centre if stroke patients were transported by primarily dispatched ground ambulance compared with a secondarily dispatched helicopter.

Background: Advances in technology have made prehospital ultrasound (US) examination available. Whether US in the prehospital setting can lead to improvement in clinical outcomes is yet unclear., Objective: The aim of this systematic review was to assess whether prehospital US improves clinical outcomes for non-trauma patients., Method: We conducted a systematic review on non-trauma patients who had an US examination performed in the prehospital setting. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the ISI Web of Science and the references of the included studies for additional relevant studies. We then performed a risk of bias analysis and descriptive data analysis., Results: We identified 1707 unique citations and included ten studies with a total of 1068 patients undergoing prehospital US examination. Included publications ranged from case series to non-randomized, descriptive studies, and all showed a high risk of bias. The large heterogeneity between the different studies made further statistical analysis impossible., Conclusion: There are currently no randomized, controlled studies on the use of US for non-trauma patients in the prehospital setting. The included studies were of large heterogeneity and all showed a high risk of bias. We were thus unable to assess the effect of prehospital US on clinical outcomes. However, consistent reports suggested that US may improve patient management with respect to diagnosis, treatment, and hospital referral., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is essential. Although primary percutaneous coronary intervention (pPCI) is the preferred revascularization technique, it often involves longer primary transportation or secondary inter-hospital transfers and thus longer system related delays. The current ESC Guidelines state that PCI should be performed within 120 minutes from first medical contact, and door-to-balloon time should be <60 minutes in order to reduce long term mortality. STEMI networks should be established with regionalization of pPCI treatment to address the challenges regarding pre-hospital treatment, triage and transport of STEMI patients and collaborations between hospitals and Emergency Medical Services (EMS). We report on a regional decade long experience from one of Europe's largest STEMI networks located in Eastern Denmark, which serves a catchment area of 2.5 million inhabitants by processing ~4000 prehospital ECGs annually transmitted from 4 EMS systems to a single pPCI center treating 1100 patients per year. This organization has led to a significant improvement of the standard of therapy for acute myocardial infarction (MI) patients leading to historically low 30-day mortality for STEMI patients (<6%). About 70-80% of all STEMI patients are being triaged from the field and rerouted to the regional pPCI center. Significant delays are still found among patients who present to local hospitals and for those who are first admitted to a local emergency room and thus subject to inter-hospital transfer. In the directly transferred group, approximately 80% of patients can be treated within the current guideline time window of 120 minutes when triaged within a 185 km (~115 miles) radius. Since 2010, a Helicopter Emergency Medical Service has been implemented for air rescue. Air transfer was associated with a 20-30 minute decrease from first medical contact to pPCI, at distances down to 90 km from the pPCI center and with a trend toward better survival among air transported patients. The pPCI center also serves a small island in the Baltic Sea, where STEMI patients are rescued via air force helicopters. Based on data from more than 100 patients transferred over the past decade, we have found a similar in-hospital and long term mortality rate compared to the main island inhabitants. In conclusion, with the optimal collaboration within a STEMI network including local hospitals, university clinics, EMS and military helicopters using the same telemedicine system and field triage of STEMI patients, most patients can be treated within the time limits suggested by the current guidelines. These organizational changes are likely to contribute to the improved mortality rate for STEMI patients., (© 2013.)

Aims: This study aimed to compare air (AIR) and ground transport (GRD) of STEMI patients bound for primary percutaneous coronary intervention (pPCI)., Methods and Results: This was a prospective, controlled, observational study, including patients in whom STEMI was suspected outside a 30-minute driving distance from the PCI centre. AIR patients in a 12-month period (May 1, 2010, to April 30, 2011) were compared with GRD patients in a 16-month period (January 1, 2010, to April 30, 2011). The primary endpoint was time from ECG consistent with STEMI to arrival in the cardiac catheterisation laboratory. We included 450 patients, 114 AIR and 336 GRD patients. The median (5-95% range) transport distance was 97 (62-162) vs. 94 (64-172) kilometres, respectively (p=0.01). Time from ECG to cardiac catheterisation laboratory arrival was significantly lower in the AIR group (median 84 minutes (60-160) vs.104 minutes [63-225], p<0.01). Time from ECG to balloon was 114 (78-221) minutes vs.132 (84-262) (p<0.01), respectively. The 30-day mortality was 2.2% (2/91) for AIR and 6.9% (18/262) for GRD patients (p=0.10). One-year mortality was 6.7%, (6/90) vs. 9.9% (26/262) (p=0.35), respectively., Conclusions: Air transport seemed superior to ground transportation in reducing time from ECG diagnosis to arrival in the catheterisation laboratory for STEMI patients outside a 30-minute driving distance to the PCI centre.

Introduction: Centralization of the hospital system entails longer transport for some patients. A physician-staffed helicopter may provide effective triage, advanced management and fast transport to highly specialized treatment for time-critical patients. The aim of this study was to describe activity and possible beneficial effect of a physician-staffed helicopter in a one-year trial period in eastern Denmark., Material and Methods: This was a prospective observational study of all missions related to a daylight operating, physician-staffed helicopter. We recorded information about the activity during 12 months, focusing on dispatchment, diagnoses, medical interventions, admission patterns and 30-day mortality., Results: There were a total of 574 missions resulting in 609 patient contacts. Activity ranged from 22 to 76 missions per month. The helicopter was grounded 6% of its operating time, mainly due to weather conditions. The primary patient categories were trauma (43.5%) and cardiac disease (26.1%). The physician acted as Medical Incident Officer at three major incidents. A total of 53 endotracheal intubations, 13 intraosseous cannula insertions and four tube thoracostomies were performed. The median hospital length-of-stay was four days, 30-day mortality was 6.1% and 86 patients were transferred to intensive care units., Conclusion: The physician-staffed helicopter had approximately two missions per day the first year, mainly in relation to trauma and cardiac patients needing specialized treatment. Advanced medical interventions were commonly performed., Funding: Funded by Trygfonden., Trial Registration: not relevant.

Helicopter transportation of ST-elevation myocardial infarction patients have verified a reduction in the overall system delay, and should be considered in case of long transportation. The most suitable location of the helicopter base is in remote areas, close to the patients to be transferred. Helipads should be adjoining the percutaneous coronary intervention centre in order to allow direct transfer without the ambulance transfer. Helicopters that can operate both day and night and in poor visibility are recommended. Specially trained physicians, able to provide the required, advanced, in-flight treatment, should staff the helicopters.

Introduction: The aim of this study was to estimate to which extent patients with abnormal vital signs on general wards had their vital signs monitored and documented and to establish if staff concern for patients influenced the level of monitoring and was predictive of increased mortality., Material and Methods: Prospective observational study at Herlev Hospital, Copenhagen, Denmark. Study personnel measured vital signs on all patients present on five wards during the evening and night and interviewed nursing staff about patients with abnormal vital signs. Subsequently, patient records were studied., Results: A total of 155 patients with abnormal vital signs were identified, and staff was interviewed about 139 patients. In 61 of these 139 patients, some vital signs were measured by staff, but the respiratory rate was not measured. In 86 cases staff decided to intervene because of abnormal vital signs measured by study personnel. A total of 77% of patients had vital signs documented in their records on the day of the observation. The previous day, vital signs were documented in 70% of records and on the day after in 66%. The documentation of vital signs was significantly higher when staff expressed concern for a patient in the patient record (95% vs. 65%, chi(2): p < 0.001), but 30-day mortality did not differ significantly (15% vs. 10%, chi(2): p = 0.40)., Conclusion: In more than half of the patients, the abnormal vital signs were not identified by staff because the vital signs were not measured. In two out of three patients, staff decided to intervene because of abnormal vital signs measured by study personnel, indicating a need to reevaluate monitoring routines at general wards.