A Psychological Resilience Briefing Intervention for Helicopter Emergency Medical Service Observers.

OBJECTIVE: Helicopter emergency medical services (HEMS) observers may be at risk of negative psychological effects associated with exposure to traumatic events during shifts. This article describes a quality improvement project for HEMS observers at Essex & Herts Air Ambulance. METHODS: A psychological resilience briefing intervention (PRBi) was developed and delivered during induction training with 60 HEMS observers. The PRBi aimed to raise awareness of traumatic events that observers may experience and provided basic education on 5 domains, including likely forms of trauma exposure, possible psychological reactions, advice on coping strategies and supporting colleagues, and resources that they could use if required. The intervention was intended to bolster resilience and reduce posttraumatic stress disorder symptoms, and to encourage adaptive coping styles in observers. RESULTS: Observers learned from and valued the PRBi; statistically significant increases were observed in awareness of the 5 domains from pre- to post-delivery, and free-text responses cited a variety of benefits to the observers. There was no indication that the PRBi caused harm. CONCLUSION: The PRBi has now been included in the routine induction of observers at Essex & Herts Air Ambulance and has the potential to be repurposed for use in other settings, including medical schools.

Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review.

BACKGROUND: This study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician-paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention. METHODS: A retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician-paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2. RESULTS: Over 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate 'primary' cricothyroidotomy was performed in 17 patients (23.6%), and 'rescue' cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%). CONCLUSIONS: This study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.

Scoping the Demand for Night Operation of Essex & Herts Air Ambulance: A Prospective Observational Study.

OBJECTIVE: Helicopter emergency medical services play an important role in the prehospital care of critically ill and injured patients, providing enhanced interventions and direct transfer to specialist centers. Essex & Herts Air Ambulance (EHAAT) delivers prehospital critical care to patients in Essex, Hertfordshire, and the surrounding areas. Historically, EHAAT's resources have not operated during the night. This study aimed to ascertain demand for prehospital critical care in Essex and Hertfordshire during night hours. METHODS: A prospective observational design was used. Data were collected by 11 critical care paramedics during night shifts on a critical care desk using an online survey. Details were recorded for incidents in Essex and Hertfordshire between 21:00 and 07:00 deemed appropriate for a prehospital critical care response. RESULTS: A total of 108 incidents were recorded across 52 nights, equating to an average of 2.08 incidents per night. For 52 incidents, there was no critical care resource available to attend. The majority of incidents fell in closer proximity to EHAAT's North Weald base than its Earls Colne base. CONCLUSION: The findings suggest a potential need for prehospital critical care during night hours in Essex and Hertfordshire and support the operation of a resource from EHAAT's North Weald base.

Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival.

OBJECTIVES: Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. DATA SOURCES: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. STUDY SELECTION: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. DATA EXTRACTION: References and data were based on relevance and author consensus. DATA SYNTHESIS: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. CONCLUSIONS: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients.

A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

RéSUMé: Une urgence sanitaire mondiale a été déclarée par l'Organisation mondiale de la Santé alors que l'épidémie de 2019-nCoV se répand dans le monde et que des cas ont été confirmés au Canada. Les patients infectés par le 2019-nCoV sont à risque d'insuffisance respiratoire et peuvent nécessiter une admission à l'unité de soins intensifs. Lors d'une prise en charge optimale de ces patients, il est indispensable de prendre soin d'exécuter rigoureusement les mesures de contrôle des infections afin de prévenir la transmission nosocomiale aux autres patients et aux travailleurs de la santé prodiguant les soins. Bien que les mécanismes précis de transmission ne soient pas encore connus, la transmission d'humain à humain peut survenir, et le risque de dissémination aérienne pendant les interventions médicales générant des aérosols est préoccupant dans certaines circonstances spécifiques. Cet article résume des considérations importantes en ce qui touche au dépistage des patients, aux contrôles environnementaux, au matériel de protection personnelle, aux mesures de réanimation (y compris l'intubation), et à la planification des activités à l'unité de soins intensifs alors que nous nous préparons à la possibilité de nouveaux cas importés ou d'éclosions locales du 2019-nCoV. Bien que la compréhension du virus 2019-nCoV continue d'évoluer, nous espérons que les leçons retenues des éclosions précédentes de maladies infectieuses telles que le syndrome respiratoire aigu sévère nous permettront d'améliorer notre degré de préparation, indépendamment du nombre de cas que nous traiterons au Canada.

Care of the child with Ebola virus disease.

OBJECTIVES: To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings. DATA SOURCES: Review of the published medical literature, World Health Organization and government documents, and expert opinion. DATA SYNTHESIS: There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented. CONCLUSIONS: Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

The Canadian Armed Forces medical response to Typhoon Haiyan.

BACKGROUND: In the setting of international disaster response, an important challenge is determining when it is appropriate to withdraw deployed assets as the acute disaster response transitions to recovery and rebuilding. We describe our experience with realtime data collection during our medical response to Typhoon Haiyan as a means to guide military aid mission parameters. METHODS: The operational medical headquarters prospectively developed a database for use in this mission. Mobile medical teams (MMTs) were deployed to provide primary care, and the nurse designated to each MMT was responsible for entering and transmitting data daily to the medical headquarters. Data collected included the MMT location, basic patient demographics, the primary reason for the encounter and any treatment provided. These encounters were then classified as disaster, acute or chronic. RESULTS: Between Nov. 16 and Dec. 16, 2013, medical care was provided to 6596 local nationals; 238 (3.6%) had disaster-related illness or injury, 4321 (65.5%) had acute postdisaster medical conditions and 2037 (30.9%) sought medical care for chronic conditions. Of the 257 patients with traumatic injuries, 28 (11%) had disaster-related injuries and 214 (83%) had acute injuries that occurred postdisaster. CONCLUSION: The data collected during the mission to the Phillippines was compiled with performance metrics from the other Disaster Assistance Response Team components to help advise the Canadian government regarding mission duration. We recommended that data collection continue on all future missions and be modified to provide further information to larger disaster coordination teams, such as the United Nations Office for the Coordination of Humanitarian Affairs.

CONTEXTE: Dans le domaine de l'intervention internationale en cas de catastrophe, il est souvent difficile de déterminer le moment approprié pour retirer les ressources déployées alors que l'on passe de la première intervention d'urgence à la période de rétablissement et de reconstruction. Nous décrirons ici notre expérience de collecte de données en temps réel durant notre intervention médicale après le typhon Haiyan, dans le but d'orienter les paramètres de mission de l'aide militaire. MÉTHODES: Le quartier général des opérations médicales avait préparé d'avance la base de données qui a été utilisée lors de cette mission. Des équipes médicales mobiles ont été déployées pour fournir des soins de base, et une infirmière ou un infirmier désigné dans chaque équipe était chargé d'entrer et de transmettre les données quotidiennement au quartier général des opérations médicales. Les données recueillies comprenaient la position de l'équipe médicale mobile, des données démographiques de base sur les patients, la raison première de la rencontre et les traitements fournis. Ces rencontres étaient ensuite classées comme catastrophiques, aiguës ou chroniques. RÉSULTANTS: Du 16 novembre au 16 décembre 2013, des soins médicaux ont été prodigués à 6596 Philippins; 238 personnes (3,6 %) avaient des maladies ou des blessures liées au typhon, 4321 personnes (65,5 %) avaient des problèmes médicaux aigus d'après catastrophe et 2037 personnes (30,9 %) avaient besoin de soins pour des affections chroniques. Des 257 patients ayant subi des lésions traumatiques, 28 (11 %) avaient des blessures liées à la catastrophe et 214 (83 %) avaient des blessures aiguës reçues après la catastrophe. CONCLUSION: Les données recueillies durant la mission aux Philippines ont été compilées avec les indicateurs de rendement des autres composantes de l'équipe d'intervention en cas de catastrophe pour conseiller le gouvernement canadien au sujet de la durée des missions. Nous recommandons que la collecte de données se poursuive durant toutes les missions futures et soit modifiée afin de fournir plus de renseignements aux plus grandes équipes de coordination des interventions en cas de catastrophe, comme le Bureau de la coordination des affaires humanitaires de l'Organisation des Nations Unies.

Patient Outcomes in Helicopter Emergency Medical Service Documentaries and on Air Ambulance Websites.

Background Helicopter emergency medical service (HEMS) documentaries attract millions of viewers, and publicly available patient stories on Air Ambulance websites are vital to raise awareness and funding for Air Ambulance charities in the United Kingdom (UK). Despite abundant research investigating how fictional programs and news outlets present patient health outcomes, there are no comprehensive studies that investigate how non-fictional HEMS documentaries or Air Ambulance websites present patient outcomes. The aim of this study is to capture the frequency of poor outcomes (mortality) in patients broadcasted on documentaries focusing on HEMS and the patient stories section of UK Air Ambulance websites. Methods A retrospective cohort study reviewed five HEMS documentaries between January 2016 and October 2019 and 20 Air Ambulance websites that had patient stories published until October 2020. In all, 628 patients identified fit the eligibility criteria: 311 from HEMS documentaries and 317 patients from Air Ambulance websites.  Results In all, 0.64% (4/628) of patients died before the hospital, including 0.96% (3/311) of patients on HEMS documentaries and 0.32% (1/317) of patients on Air Ambulance websites. In addition, 2.23% (14/628) of patients died according to their final mention in the data source, including 1.93% (6/311) of patients on HEMS documentaries and 2.52% (8/317) of patients on Air Ambulance websites. Conclusions This study suggests under-reporting of poor patient outcomes in HEMS documentaries and on UK Air Ambulance websites. This could be attributed to the logistical and ethical implications of capturing and presenting poor outcomes but likely impacts upon public perception. Medical professionals should recognize this in order to proactively address potential misconceptions when communicating with patients and their families.

Collateral impact of a hospital outbreak of Clostridium difficile: an unrecognized surge event requiring a system-level response.

This paper discusses a unique surge event caused by an outbreak of Clostridium difficile, resulting not from an increase in the demands on the healthcare system but, rather, from a substantial decrease in the capacity to provide care when the medical capacity in the facility was decreased by 50% due to bed closures. Approaches to managing the situation using the staff, stuff and space paradigm are presented as strategies to prevent future adverse medical events.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care.

BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Clinical characteristics, risk factors and outcomes in patients with severe COVID-19 registered in the International Severe Acute Respiratory and Emerging Infection Consortium WHO clinical characterisation protocol: a prospective, multinational, multicentre, observational study.

Due to the large number of patients with severe coronavirus disease 2019 (COVID-19), many were treated outside the traditional walls of the intensive care unit (ICU), and in many cases, by personnel who were not trained in critical care. The clinical characteristics and the relative impact of caring for severe COVID-19 patients outside the ICU is unknown. This was a multinational, multicentre, prospective cohort study embedded in the International Severe Acute Respiratory and Emerging Infection Consortium World Health Organization COVID-19 platform. Severe COVID-19 patients were identified as those admitted to an ICU and/or those treated with one of the following treatments: invasive or noninvasive mechanical ventilation, high-flow nasal cannula, inotropes or vasopressors. A logistic generalised additive model was used to compare clinical outcomes among patients admitted or not to the ICU. A total of 40 440 patients from 43 countries and six continents were included in this analysis. Severe COVID-19 patients were frequently male (62.9%), older adults (median (interquartile range (IQR), 67 (55-78) years), and with at least one comorbidity (63.2%). The overall median (IQR) length of hospital stay was 10 (5-19) days and was longer in patients admitted to an ICU than in those who were cared for outside the ICU (12 (6-23) days versus 8 (4-15) days, p<0.0001). The 28-day fatality ratio was lower in ICU-admitted patients (30.7% (5797 out of 18 831) versus 39.0% (7532 out of 19 295), p<0.0001). Patients admitted to an ICU had a significantly lower probability of death than those who were not (adjusted OR 0.70, 95% CI 0.65-0.75; p<0.0001). Patients with severe COVID-19 admitted to an ICU had significantly lower 28-day fatality ratio than those cared for outside an ICU.

Pandemic H1N1 influenza infection and vascular thrombosis.

During the summer and fall of 2009, significant thrombotic events were observed in patients infected with the pandemic H1N1 influenza A virus. In a retrospective chart review of 119 individuals admitted to the hospital with H1N1 virus infection, 7 patients (5.9%) were found to have experienced thrombotic vascular events.

Ethical issues in pediatric emergency mass critical care.

INTRODUCTION: As a result of recent events, including natural disasters and pandemics, mass critical care planning has become a priority. In general, planning involves limiting the scope of disasters, increasing the supply of medical resources, and allocating scarce resources. Entities at varying levels have articulated ethical frameworks to inform policy development. In spite of this increased focus, children have received limited attention. Children require special attention because of their unique vulnerabilities and needs. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subgroups by topic area and performed literature reviews of MEDLINE and Ovid databases. Draft documents were subsequently developed and revised based on the feedback from the Task Force. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. This document reflects expert input from the Task Force in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: The Ethics Subcommittee recommends that surge planning seek to provide resources for children in proportion to their percentage of the population or preferably, if data are available, the percentage of those affected by the disaster. Generally, scarce resources should be allocated on the basis of need, benefit, and the conservation of resources. Estimates of need, benefit, and resource utilization may be more subjective or objective. While the Subcommittee favors more objective methods, pediatrics lacks a simple, validated scoring system to predict benefit or resource utilization. The Subcommittee hesitantly recommends relying on expert opinion while pediatric triage tools are developed. If resources remain inadequate, they should then be allocated based on queuing or lottery. Choosing between these methods is based on ethical, psychological, and practical considerations upon which the Subcommittee could not reach consensus. The Subcommittee unanimously believes the proposal to favor individuals between 15 and 40 yrs of age is inappropriate. Other age-based criteria and criteria based on social role remain controversial. The Subcommittee recommends continued work to engage all stakeholders, especially the public, in deliberation about these issues.

Treatment and triage recommendations for pediatric emergency mass critical care.

INTRODUCTION: This paper will outline the Task Force recommendations regarding treatment during pediatric emergency mass critical care, issues related to the allocation of scarce resources, and current challenges in the development of pediatric triage guidelines. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: Recommendations are divided into three operational sections. The first section provides pediatric emergency mass critical care recommendations for hospitals that normally provide care to pediatric patients. The second section provides recommendations for pediatric emergency mass critical care at hospitals that do not routinely provide care to pediatric patients. The final section provides a discussion of issues related to developing triage algorithms and protocols and the allocation of scarce resources during pediatric emergency mass critical care.

Critical care outcomes, for the first 200 patients with confirmed COVID-19, in England, Wales and Northern Ireland: A report from the ICNARC Case Mix Programme.

BACKGROUND: Early in a pandemic, outcomes are biased towards patients with shorter durations of critical illness. We describe 60-day outcomes for patients critically ill with confirmed COVID-19 and explore the potential bias in the weekly reported data by ICNARC. METHODS: First 200 consecutive patients with confirmed COVID-19, admitted for critical care in England, Wales and Northern Ireland, followed-up for a minimum of 60 days from admission. Outcomes included survival and duration of critical care, receipt/duration of organ support in critical care and hospital survival. RESULTS: Mean age was 62.6 years, 70.5% were male, 52.0% were white, 39.2% obese and 9.0% had serious comorbidities. Median APACHE II score was 16 (IQR 12, 19). After 60 days, 83 (41.5%) patients had been discharged from hospital, 15 (7.5%) had been discharged from critical care but remained in hospital, 1 (0.5%) was still receiving critical care, 90 (45.0%) had died while receiving critical care and 11 (5.5%) had died in hospital after discharge from critical care. Median duration of critical care was 14.0 days (IQR 6.1, 23.0) for survivors and 10.0 days (IQR 5.0, 16.0) for non-survivors of critical care. Overall, 158 (79.0%) patients received advanced respiratory support for a median of 13 (IQR 8, 20) calendar days. Compared with weekly reports during the pandemic, critical care mortality started higher than but then decreased below that of the first 200 consecutive patients. Duration of critical care, for both survivors and non-survivors increased over time; however, both were still lower than those for the first 200 consecutive patients. Receipt and duration of organ support increased to values similar to those for the first 200 consecutive patients. CONCLUSION: COVID-19 in critical care has high mortality and places a large burden on resources. Analysis of preliminary data with limited follow-up should be interpreted with caution, particularly for future planning in a pandemic.

Point-of-care ultrasound (POCUS) practices in the helicopter emergency medical services in Europe: results of an online survey.

BACKGROUND: The extent to which Point-of-care of ultrasound (POCUS) is used in different European helicopter EMS (HEMS) is unknown. We aimed to study the availability, perception, and future aspects of POCUS in the European HEMS using an online survey. METHOD: A survey about the use of POCUS in HEMS was conducted by a multinational steering expert committee and was carried out from November 30, 2020 to December 30, 2020 via an online web portal. Invitations for participation were sent via email to the medical directors of the European HEMS organizations including two reminding notes. RESULTS: During the study period, 69 participants from 25 countries and 41 different HEMS providers took part in the survey. 96% (n = 66) completed the survey. POCUS was available in 75% (56% always when needed and 19% occasionally) of the responding HEMS organizations. 17% were planning to establish POCUS in the near future. Responders who provided POCUS used it in approximately 15% of the patients. Participants thought that POCUS is important in both trauma and non-trauma-patients (73%, n = 46). The extended focused assessment sonography for trauma (eFAST) protocol (77%) was the most common protocol used. A POCUS credentialing process including documented examinations was requested in less than one third of the HEMS organizations. CONCLUSIONS: The majority of the HEMS organizations in Europe are able to provide different POCUS protocols in their services. The most used POCUS protocols were eFAST, FATE and RUSH. Despite the enthusiasm for POCUS, comprehensive training and clear credentialing processes are not available in about two thirds of the European HEMS organizations. Due to several limitations of this survey further studies are needed to evaluate POCUS in HEMS.

The US Strategic National Stockpile Ventilators in Coronavirus Disease 2019: A Comparison of Functionality and Analysis Regarding the Emergency Purchase of 200,000 Devices.

BACKGROUND: Early in the coronavirus disease 2019 (COVID-19) pandemic, there was serious concern that the United States would encounter a shortfall of mechanical ventilators. In response, the US government, using the Defense Production Act, ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities, and whether all are able to support COVID-19 patients is not evident. RESEARCH QUESTION: Evaluate ventilator requirements for affected COVID-19 patients, assess the clinical performance of current US Strategic National Stockpile (SNS) ventilators employed during the pandemic, and finally, compare ordered ventilators' functionality based on COVID-19 patient needs. STUDY DESIGN AND METHODS: Current published literature, publicly available documents, and lay press articles were reviewed by a diverse team of disaster experts. Data were assembled into tabular format, which formed the basis for analysis and future recommendations. RESULTS: COVID-19 patients often develop severe hypoxemic acute respiratory failure and adult respiratory defense syndrome (ARDS), requiring high levels of ventilator support. Current SNS ventilators were unable to fully support all COVID-19 patients, and only approximately half of newly ordered ventilators have the capacity to support the most severely affected patients; ventilators with less capacity for providing high-level support are still of significant value in caring for many patients. INTERPRETATION: Current SNS ventilators and those on order are capable of supporting most but not all COVID-19 patients. Technologic, logistic, and educational challenges encountered from current SNS ventilators are summarized, with potential next-generation SNS ventilator updates offered.