[Physician-assisted interhospital transfer-an analysis from Schleswig-Holstein]. / Arztbegleitete Interhospitaltransporte ­ eine Analyse aus Schleswig-Holstein.

BACKGROUND: The need for interhospital transport (IHT) of intensive care patients is increasing due to changes in the hospital environment. Interhospital transports are challenging and require careful operational planning of personnel and rescue vehicles. OBJECTIVE: To investigate the need for IHT, an analysis was conducted in the service area of the emergency medical service central dispatch center (IRLS) in Schleswig-Holstein. MATERIAL AND METHODS: Emergency physician-assisted IHT were analyzed in the period from 01.10.2021 to 30.09.2022. RESULTS: Of a total of 158,823 documented IRLS missions, 2264 (1.4%) records could be identified and included as IHT: 1389 IHT (61.4%) were managed by specialized ambulances, 875 (38.6%) by primary care ambulances. Primary care ambulances were mainly used for time-critical transfers and outside the duty hours of the intensive care ambulances, 21.2 % were by air. Of all IHT, 43.1% were required to hospitals with a higher level of medical care. CONCLUSION: Emergency physician-assisted IHT are a relevant part of the emergency service's operational spectrum and concern both primary care and specialized rescue vehicles. A relevant number of urgent IHT were recorded outside the duty hours of the intensive care ambulances. For emergency transports during nighttime, an expansion of air-based transfer capacities should be considered due to the time advantage. For less urgent IHT, an adjustment of the capacities of specialized ground-based vehicles in Schleswig-Holstein seems reasonable.

Analysis of Air Rescue for Offshore Wind Energy: A Retrospective Analysis of Structural and Process Quality for the Years 2014 to 2017.

In order to achieve the emission targets required by the German Federal Environment Agency (Umweltbundesamt), the offshore wind industry has become 1 of the central building blocks of the so-called "energy turnaround." After the first offshore wind farm (OWF), Alpha Ventus, started operation in 2010, the number of OWFs in the North Sea and Baltic Sea has grown steadily. Because of the ongoing growth of the industry, the number of workers on-site has more than quadrupled in recent years. Although the majority of OWFs are located in the exclusive economic zone up to 130 km from the mainland, the same legal provisions of the Occupational Health and Safety Act (Arbeitsschutzgesetz) apply here as on the mainland. This means that the operators of the wind farms are legally obligated to maintain a seamless rescue chain. Because of the distance to the mainland, rescue helicopters are the means of choice to ensure prompt emergency preclinical care and, if necessary, rapid evacuation. The company Northern HeliCopter GmbH, part of the DRF Luftrettung since 2019, offers as part of WINDEACare rescue helicopters stationed at 3 locations on the North Sea and Baltic Sea to its contract partners an emergency medical staffed air rescue service, which is operational 24 hours a day, 365 days a year. This article is the first to provide a detailed overview of a new field in prehospital emergency care on the high seas and, to this end, has recorded all offshore missions performed from 2014 through 2017 with evaluation of related medical and aeronautical data.

[Ultrasound diagnostics in prehospital emergency care-do we need a standardized educational approach?] / Ultraschalldiagnostik in der prähospitalen Notfallmedizin ­ brauchen wir eine standardisierte Ausbildung?

BACKGROUND: Limited diagnostic capabilities represent an ongoing obstacle in out-of-hospital emergency settings. Prehospital deployment of ultrasound might reduce this particular diagnostic gap. So far, little is known about the availability and usage of ultrasound in emergency medical services (EMS) or about the level of education of EMS physicians regarding prehospital ultrasound (point-of-care ultrasound, POCUS). METHODS: A nationwide survey was conducted among emergency physicians in Germany focusing on POCUS education and experience. RESULTS: Between 02/2022 and 05/2022, 1079 responses were registered, of which 853 complete responses were analyzed. Of the emergency physicians, 71.9% consider POCUS beneficial for out-of-hospital diagnostics and 43.8% had participated in a certified POCUS training prior to the survey. The self-evaluation of POCUS skills among emergency physicians depended significantly on their participation in a certified training (p < 0.001) and frequent ultrasound routine (p < 0.001). CONCLUSION: The majority of participating emergency physicians in Germany consider POCUS to improve out-of-hospital diagnostic capabilities. Participation in a certified POCUS training and frequent use of ultrasound facilitated higher self-confidence in POCUS skills.

[Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. / Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN.

Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.

[Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. / Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN.

Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.

Second Victims among German Emergency Medical Services Physicians (SeViD-III-Study).

BACKGROUND: Patient care in the prehospital emergency setting is error-prone. Wu's publications on the second victim syndrome made very clear that medical errors may lead to severe emotional injury on the caregiver's part. So far, little is known about the extent of the problem within the field of prehospital emergency care. Our study aimed at identifying the prevalence of the Second Victim Phenomenon among Emergency Medical Services (EMS) physicians in Germany. METHODS: Web-based distribution of the SeViD questionnaire among n = 12.000 members of the German Prehospital Emergency Physician Association (BAND) to assess general experience, symptoms and support strategies associated with the Second Victim Phenomenon. RESULTS: In total, 401 participants fully completed the survey, 69.1% were male and the majority (91.2%) were board-certified in prehospital emergency medicine. The median length of experience in this field of medicine was 11 years. Out of 401 participants, 213 (53.1%) had experienced at least one second victim incident. Self-perceived time to full recovery was up to one month according to 57.7% (123) and more than one month to 31.0% (66) of the participants. A total of 11.3% (24) had not fully recovered by the time of the survey. Overall, 12-month prevalence was 13.7% (55/401). The COVID-19 pandemic had little effect on SVP prevalence within this specific sample. CONCLUSIONS: Our data indicate that the Second Victim Phenomenon is very frequent among prehospital emergency physicians in Germany. However, four out of ten caregivers affected did not seek or receive any assistance in coping with this stressful situation. One out of nine respondents had not yet fully recovered by the time of the survey. Effective support networks, e.g., easy access to psychological and legal counseling as well as the opportunity to discuss ethical issues, are urgently required in order to prevent employees from further harm, to keep healthcare professionals from leaving this field of medical care and to maintain a high level of system safety and well-being of subsequent patients.

Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service.

BACKGROUND: Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons. METHODS: This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed. RESULTS: Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4. CONCLUSIONS: German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide. TRIAL REGISTRATION: The study has been retrospectively registered at DRKS (DRKS00026222).

[Ethical aspects of mechanical resuscitation in a child : Results of an expert workshop within the BMBF project CLAIRE-Children's Automated Intelligent Resuscitation]. / Ethische Aspekte mechanischer Reanimationshilfen beim Kind : Ergebnisse eines Expertenworkshops im Rahmen des BMBF-Projekts CLAIRE ­ Children's Automated Intelligent Resuscitation.

BACKGROUND: While the use of mechanical resuscitation devices can be considered for adult resuscitation, the European Resuscitation Council guidelines do not yet mention their use for pediatric resuscitation. Only one device has been partially approved for use in children; further pediatric appliances are currently being used off-label. Ethical considerations arising from the use of mechanical resuscitation devices have not yet been presented in a structured way. OBJECTIVE: To elaborate ethical considerations in the development phase of mechanical resuscitation devices for children. METHODS: Based on several fictitious case reports, an interdisciplinary expert focus group discussion was conducted. This was followed by a moderated discussion, summarizing the results. Guiding principles and research desiderata were formulated using these results as well as existing literature. RESULTS: According to the group of experts, ethical considerations regarding mechanical resuscitation devices in pediatrics predominantly concern the subject of indication and discontinuation criteria. Ethical aspects concerning psychosocial impacts on affected families and intervention teams cannot be generalized and need to be analyzed on a case-by-case basis. CONCLUSION: The considerations presented regarding the use of mechanical resuscitation devices in the pediatric context, which is still in its developmental stage, could also have practical implications for adult out-of-hospital resuscitation decisions. Concerning ethical aspects of out-of-hospital resuscitation decisions, especially using mechanical resuscitation devices, the need for accompanying empirical research is substantial.

Association between the experience of violence and burnout among paramedics.

PURPOSE: Similar to many occupational groups in the rescue service, paramedics show increased mental health problems. Both situational and work-organizational factors play a role in the development of mental illnesses. The aim of the study is to investigate the connection of experienced violence and the development of burnout in the paramedical profession. METHODS: To analyze this association, 358 paramedics working for a German metropolitan fire brigade were examined using the Hamburg burnout inventory and a questionnaire on the history of violence, using one-factorial variance analyses, t tests and regression analyses. RESULTS: The examined sample did not show elevated burnout rates, but 97.5% reported that they had already been insulted or spit on while in service. The experience of feeling threatened proved to be a significant predictor for emotional exhaustion and an aggressive response to emotional stress. Also, the experience of being jailed or insulted and the number of years of service are associated with the burnout score. All other experiences showed no significant association with the burnout burden. CONCLUSION: It can be concluded that specific experiences with violence in the service of paramedics can particularly be associated with burnout symptoms. In general, however, violence seems to play a minor role.

[Prehospital treatment of tension pneumothorax in children-which decisions do we make? : Results of a survey among German emergency physicians]. / Die prähospitale Therapie eines Spannungspneumothorax bei Kindern ­ welche Entscheidungen treffen wir? : Ergebnisse einer Umfrage unter deutschen Notärzten.

BACKGROUND: The preclinical treatment of a traumatic or spontaneous tension pneumothorax remains a particular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training. OBJECTIVE: In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians. MATERIAL AND METHODS: An online survey was conducted with 43 questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich. RESULTS: More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children. CONCLUSION: Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers a large amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing a tension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.

Blood Product Supply for a Helicopter Emergency Medical Service.

BACKGROUND: Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. METHODS: A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. RESULTS: The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. CONCLUSIONS: Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.

Videolaryngoscopy for Physician-Based, Prehospital Emergency Intubation: A Prospective, Randomized, Multicenter Comparison of Different Blade Types Using A.P. Advance, C-MAC System, and KingVision.

BACKGROUND: Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied. METHODS: We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests (P[BF]). All presented P values are adjusted for center. RESULTS: Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13-7.42, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31-2.53, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055-0.38, P[BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043-.34, P[BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device. CONCLUSIONS: During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.

[Injuries caused by acids and bases - emergency treatment]. / Verletzungen durch Säuren und Laugen - Versorgung im Rettungsdienst.

Emergency medical care for injuries caused by acids and bases is challenging for rescue services. They have to deal with operational safety, detection of the toxic agent, emergency medical care of the patient and handling of the rescue mission. Because of the rareness of such situations experience and routine are largely missing. This article highlights some basic points for the therapy and provides support for such rescue missions.

[Invasive emergency techniques--cricothyroidotomy]. / Invasive Notfalltechniken--Die Koniotomie.

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of cricothyroidotomy on adults and children, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques.

[Invasive emergency techniques--decompression of the pleura]. / Invasive Notfalltechniken--Entlastung des Pleuraraumes.

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. Beside a theoretical education, practice-oriented course concepts are necessary to achieve a high quality of these measures. This article presents the use of decompression of the pleura on adults and children, with reference to indication, implementation, problems and risks. It is the second part of a series of four articles on the subject of invasive emergency techniques.

[Organisation and scheduling of interhospital intensive care patient transport]. / Interhospitaltransfer--Planung und Vorbereitung von Intensivtransporten / -verlegungen.

The need for interhospital transfer of intensive care and high risk patients is increasing. These transfers are dangerous and challenging. Successful organisation and scheduling includes the appropriate selection of the transport vehicle and the preliminary consultation and cooperation of all participants according to predefined rules. This article describes definitions and fundamentals, specific characteristics of different transport vehicles, recommended consultation and typical pitfalls.

[Serious complications following a marathon run: interactive case report of a dramatic course]. / Kasuistik interaktiv - Ein Marathon mit dramatischen Folgen.

A marathon runner collapses after crossing the finish line and shows neurological disorders. Aftertreatment at the scene hyponatremia and cerebral edema are found at hospital admission. Thepatient is treated for "exercise-associated hyponatremia" (EAH) on the ICU for six days. This raredisease occurs following endurance exercise and is based on an acute dilutionalhyponatremia.Symptoms include nausea and vomiting, desorientation, dizziness, seizures or coma. Therapyincludes fluid restriction and application of hypertonic saline. Plasma sodium concentration shouldbe checked at the scene in all collapsed athletes showing neurological symptoms to differentiatebetween exercise-associated hyponatremia and dehydration.

Regional ventilation distribution determined by electrical impedance tomography: reproducibility and effects of posture and chest plane.

BACKGROUND AND OBJECTIVE: Reliable assessment of regional lung ventilation and good reproducibility of electrical impedance tomography (EIT) data are the prerequisites for the future application of EIT in a clinical setting. The aims of our study were to determine (i) the reproducibility of repeated EIT measurements and (ii) the effect of the studied transverse chest plane on ventilation distribution in different postures. METHODS: Ten healthy adult subjects were studied in three postures on two separate days. EIT and spirometric data were obtained during tidal breathing and slow vital capacity (VC) manoeuvres. EIT data were acquired in two chest planes at 13 scans/s. Reproducibility of EIT findings was assessed by Bland-Altman analysis and Pearson correlation in 16 regions of interest in each plane. Regional ventilation distribution during tidal breathing and deep expiration was determined as fractional ventilation in four quadrants of the studied chest cross-sections. RESULTS: Our study showed a good reproducibility of EIT measurements repeated after an average time interval of 8 days. Global tidal volumes and VCs determined by spirometry on separate days were not significantly different. Regional ventilation in chest quadrants assessed by EIT was also unaffected. Posture exerted a significant effect on ventilation distribution among the chest quadrants during spontaneous breathing and deep expiration in both planes. The spatial distribution patterns in the two planes were not identical. CONCLUSIONS: We conclude that regional EIT ventilation findings are reproducible and recommend that the EIT examination location on the chest is carefully chosen especially during repeated measurements and follow-up.