[Prehospital chest tube placement: Which factors are associated with feeling confident to perform the procedure?] / Prähospitale Anlage von Thoraxdrainagen: Welche Faktoren sind mit einem subjektivem Sicherheitsgefühl assoziiert?

BACKGROUND: The prehospital placement of chest tubes is a rare but potentially life-saving procedure. A high level of subjective confidence with the procedure is essential for emergency medical doctors. This study aims to identify if there is a statistically significant difference in the subjective sense of confidence in prehospital chest tube placement regarding medical experience and qualification, clinical routine, and attendance at simulation courses. METHODS: Prehospital emergency physicians of three emergency medical services in Southwest Saxony, Greifswald, and Vechta, Germany, were invited to participate in an online survey from January to March 2022 using the online survey service limesurvey. The question "Do you feel confident in chest tube placement?" was used to measure the subjective level of confidence. Answers were compared with data concerning medical qualification, experience in prehospital emergency medicine, clinical routine, and attendance at simulation courses. Statistical analysis was performed using chi-squared test and Fisher's exact test. RESULTS: Three out of four participants felt confident in chest tube placement (53/71; 74.6%). More than half of the participants reported that they did not perform this procedure regularly (35/53, 66%). Subjective confidence was highest in physicians who regularly place chest tubes during their non-prehospital work (34/37; 91,9%; p<0.001), and more often when participants had clinical routine and attended simulation courses than when none of this applied (p=0.012). Attendance at simulation courses alone was not associated with a higher level of confidence (p=0.002). Specialists showed significantly more often subjective confidence in chest tube placement (p=0.0401). CONCLUSION: Prehospital chest tube placement is rare, but potentially lifesaving. An adequately high level of subjective confidence in the placement of chest tubes is a key condition for prehospital emergency doctors. Inhospital clinical routine and attendance at simulation courses are significantly associated with high levels of confidence. Our data indicate that working only in prehospital emergency settings without further clinical routine or medical specialization is not sufficient for achieving and ensuring subjective confidence in chest tube placement.

A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint.

PURPOSE: Climate change is a global threat, and inhalational anesthetics contribute to global warming by altering the photophysical properties of the atmosphere. On a global perspective, there is a fundamental need to reduce perioperative morbidity and mortality and to provide safe anesthesia. Thus, inhalational anesthetics will remain a significant source of emissions in the foreseeable future. It is, therefore, necessary to develop and implement strategies to minimize the consumption of inhalational anesthetics to reduce the ecological footprint of inhalational anesthesia. SOURCE: We have integrated recent findings concerning climate change, characteristics of established inhalational anesthetics, complex simulative calculations, and clinical expertise to propose a practical and safe strategy to practice ecologically responsible anesthesia using inhalational anesthetics. PRINCIPAL FINDINGS: Comparing the global warming potential of inhalational anesthetics, desflurane is about 20 times more potent than sevoflurane and five times more potent than isoflurane. Balanced anesthesia using low or minimal fresh gas flow (≤ 1 L·min-1) during the wash-in period and metabolic fresh gas flow (0.35 L·min-1) during steady-state maintenance reduces CO2 emissions and costs by approximately 50%. Total intravenous anesthesia and locoregional anesthesia represent further options for lowering greenhouse gas emissions. CONCLUSION: Responsible anesthetic management choices should prioritize patient safety and consider all available options. If inhalational anesthesia is chosen, the use of minimal or metabolic fresh gas flow reduces the consumption of inhalational anesthetics significantly. Nitrous oxide should be avoided entirely as it contributes to depletion of the ozone layer, and desflurane should only be used in justified exceptional cases.

RéSUMé: OBJECTIF: Les changements climatiques constituent une menace mondiale et les anesthésiques volatils contribuent au réchauffement climatique en modifiant les propriétés photophysiques de l'atmosphère. Dans une perspective mondiale, il est fondamentalement nécessaire de réduire la morbidité et la mortalité périopératoires et de procurer une anesthésie sécuritaire. Par conséquent, les agents volatils demeureront une source importante d'émissions dans un avenir proche. Il est donc nécessaire d'élaborer et de mettre en œuvre des stratégies pour minimiser la consommation d'anesthésiques volatils afin de réduire l'empreinte écologique de l'anesthésie par inhalation. SOURCES: Nous avons intégré les découvertes récentes concernant les changements climatiques, les caractéristiques des anesthésiques volatils connus, des calculs de simulation complexes et l'expertise clinique pour proposer une stratégie pratique et sécuritaire pour exercer une anesthésie écologiquement responsable en utilisant des anesthésiques volatils. CONSTATATIONS PRINCIPALES: En comparant le potentiel de réchauffement planétaire des anesthésiques volatils, le desflurane est environ 20 fois plus puissant que le sévoflurane et cinq fois plus puissant que l'isoflurane. Une anesthésie équilibrée avec un débit de gaz frais faible ou minimal (≤ 1 L·min-1) pendant la période de mise en route ('wash-in') et le débit métabolique de gaz frais (0,35 L·min-1) pendant le maintien à l'état d'équilibre réduit le CO2 et les coûts d'environ 50 %. L'anesthésie intraveineuse totale et l'anesthésie locorégionale représentent d'autres options pour réduire les émissions de gaz à effet de serre. CONCLUSION: Les choix responsables en matière de prise en charge anesthésique devraient accorder la priorité à la sécurité des patients et à l'évaluation de toutes les options disponibles. Si l'anesthésie par inhalation est choisie, l'utilisation d'un débit minimal ou métabolique de gaz frais réduit considérablement la consommation d'anesthésiques volatils. Le protoxyde d'azote doit être complètement évité car il contribue à l'appauvrissement de la couche d'ozone, et le desflurane ne doit être utilisé que dans les cas exceptionnels et justifiés.

[Safety aspects of prehospital thoracic emergency procedures: Results of a survey among German emergency physicians]. / Sicherheitsaspekte invasiver thorakaler Maßnahmen in der prähospitalen Notfallmedizin ­ Ergebnisse einer Umfrage unter deutschen Notärzt:innen.

BACKGROUND: The safe indication and performance of thoracic emergency procedures are crucial and potentially lifesaving in prehospital emergency care. This study aims to investigate issues of patient safety and quality assurance of prehospital invasive thoracic interventions. The survey does not represent the actual medical care situation but explores reasons for security concerns among emergency physicians. METHODS: Using a pre-validated questionnaire, prehospital emergency physicians of three prehospital rescue associations (Zweckverband) in Southwest Saxony, Greifswald, and Vechta, Germany, were queried via the online survey service limesurvey. The survey was conducted between January and March 2022. RESULTS: 104 emergency physicians participated (response rate 42.4%) 71 of which fully completed the survey (68%). 79% of the participants stated that they felt safe in performing pleural punction. Common reasons for postponing prehospital thoracic interventions included fear of complications or individual patient characteristics. 90% said that they were familiar with the on-board equipment options, and 60% reported that resources were sufficient to perform double-sided procedures. While in all three regions there is sufficient on-board equipment to perform procedures on two sides, one out of two participants said that lack of equipment deters them from performing prehospital invasive thoracic procedures. Emergency physicians who graduated from trauma courses and/or participate in air rescue are more likely to perform invasive thoracic procedures. More than half of the participants wanted more training in chest tube placement or pleural punction. CONCLUSION: Safety in prehospital invasive thoracic procedures needs improvement in structural, procedural, as well as human factors aspects. Safe handling of these rare but vital techniques requires more training. A lack of knowledge of equipment is a significant safety gap. Prehospital ultrasound constitutes a structural element of prehospital diagnostics.

[Technology-enhanced learning in anesthesiology and emergency medicine : A new approach to medical school teaching in the wake of the pandemic]. / "Technology-enhanced learning" in Anästhesiologie und Notfallmedizin : Ein neuer Weg in der studentischen Lehre im Schatten der Pandemie.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has brought about unprecedented challenges to medical schools. Physical distancing as the most effective means of infection prevention renders traditional classroom teaching nearly impossible and new teaching methods are required to contain the infection risk whilst ensuring high-level education. OBJECTIVE: In order to minimize the need for classroom teaching we have created an interactive multimedia eLearning environment using the open-source learning management system "Moodle". This article describes the development of the eLearning environment and aims to establish the acceptance of technology-enhanced learning (TEL) among medical students and the evaluation of TEL as an alternative to classroom teaching. MATERIAL AND METHODS: We have built a multimedia eLearning environment for fourth year medical students covering the medical school curriculum "anesthesiology and emergency medicine", which is based on the recommendations of the German Society for Anesthesiology and Intensive Care Medicine (DGAI). We have chosen the open-source learning management system "Moodle" as a platform. "Moodle" is widely used by Anglo-American educational institutions to support and conduct academic and nonacademic teaching. In order to assess the students' experience, we have carried out an anonymized post-course survey consisting of multiple-choice and free-answer questions. RESULTS: Of the 157 participants 85.4% rated the course as "very good", 12.1% as "good" and 1.9% as "OK". Lower ratings were not given, 54.8% rated the course content as "very relevant", 43.3% as "relevant" and 1.9% as "neutral", 94.3% felt that more comparable online courses should be offered. The free-text answers revealed that accessibility and multimedia self-controlled learning were highly valued; however, it was felt that hands-on training cannot be replaced by eLearning. CONCLUSION: Technology Enhanced Learning was highly valued by our students and helped to reduce the need for classroom teaching; however, for teaching practical skills classroom teaching remains indispensable.

Improved Diagnosis of Iron Deficiency Anemia in the Critically Ill via Fluorescence Flowcytometric Hemoglobin Biomarkers.

BACKGROUND: Iron deficiency anemia (IDA) is common in critically ill patients treated in the intensive care unit (ICU), and it can lead to severe consequences. Precise and immediate diagnostics are not available, but they are inevitably needed to administer adequate therapy. Serological parameters such as serum ferritin and transferrin saturation (TSAT) are heavily influenced by simultaneous inflammation reactions, resulting in the need for more suitable parameters. Reticulocyte biomarkers such as reticulocyte hemoglobin content (RET-He) and Delta-hemoglobin equivalent (Delta-He) determined by fluorescence flowcytometry are more specific for the diagnosis of IDA-based anemia and should be investigated for this purpose. METHODS: In a prospective cohort single-center study, serum ferritin and transferrin saturation (TSAT) were collected and compared to RET-He and Delta-He by performing a receiver operating curve (ROC) analysis. The sensitivity and specificity of a single variable or the combination of two variables, as well as cutoff values, for the diagnosis of IDA were calculated. A group comparison for IDA patients without IDA was performed for a control group. RESULTS: A total of 314 patients were enrolled from an interdisciplinary ICU. RET-He (area under the curve (AUC) 0.847) and Delta-He (AUC 0.807) did indicate iron-deficient anemia that was more specific and sensitive in comparison to serum ferritin (AUC 0.678) and TSAT (AUC 0.754). The detection of functional iron deficiency (FID) occurred in 28.3% of cases with anemia. CONCLUSIONS: Determination of RET-He and Delta-He allows for the increased precision and sensitivity of iron-deficient anemia in the ICU.

Diagnosing skin disease in primary care: a qualitative study of GPs' approaches.

BACKGROUND: Skin diseases are a common reason for consulting a GP. This regular occurrence happens despite most GPs' lack of knowledge and training in skin disease. OBJECTIVES: We aimed to explore different diagnostic approaches of GPs in patients presenting with a dermatological problem. In addition, we aimed to identify strategies used by GPs to handle diagnostic uncertainty in these patients. METHODS: We conducted interviews (20-40 minutes) with 14 GPs using a semi-structured guideline. Recalling encounters with patients with skin disease, GPs described their individual diagnostic strategies. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters using a deductive-inductive approach. RESULTS: We identified several aspects of a complex decision-making process in GPs' diagnostic management of patients with dermatological problems. In the general diagnostic workup, GPs used a broad spectrum of different strategies such as spot diagnosis, stepwise refinement, pattern recognition trigger or test of treatment. GPs reduced diagnostic uncertainty through the identification of red flags, the application of the test of time, therapeutic trials and asking for further advice, including patient referral. CONCLUSIONS: GPs encounter a broad range of dermatological problems in their daily work using a variety of strategies in the workup of these patients. However, in a significant number of patients, there remains diagnostic uncertainty that is mainly reduced by specialist referral. Regular training in the diagnosis and treatment of common dermatological diseases should be offered to all GPs.