Current postgraduate training in emergency medicine in the Nordic countries.

BACKGROUND: Emergency Medicine (EM) is an independent specialty in all five Nordic countries. This study aims to evaluate the structure of post-graduate EM training in the area. METHODS: A leading hospital or hospitals in EM training in each country were identified. An e-survey was sent to each hospital to gather data on patient volume and physician staffing, curriculum, trainee supervision, and monitoring of progression in training. RESULTS: Data were collected from one center in Iceland and Norway, two in Finland and Sweden, and four centers in Denmark. The data from each country in Denmark, Finland, and Sweden, were pooled to represent that country. The percentage of consultants with EM specialist recognition ranged from 49-100% of all consultants working in the participating departments. The number of patients seen annually per each full time EM consultant was almost three times higher in Finland than in Sweden. In Iceland, Denmark, and Sweden a consultant was present 24/7 in the ED but not in all centers in the other countries. The level of trainee autonomy in clinical practice varied between countries. Requirements for completing standardized courses, completing final exams, scientific and quality improvement projects, and evaluation of trainee progression, varied between the countries. CONCLUSIONS: All Nordic countries have established EM training programs. Despite cultural similarities, there are significant differences in how the EM training is structured between the countries. Writing and implementing a standardized training curriculum and assessment system for EM training in the Nordic countries should be considered.

[Training of Icelandic rural doctors in managing trauma and acute illness].

INTRODUCTION: Rural medicine is in many ways different from urban primary care. In addition to providing primary care for a population, the rural doctor is tasked with the initial evaluation and stabilization of all emergencies usually managed by an Emergency Department in urban areas. The goal of this study was to assess rural doctors' in Iceland attendance of courses in Emergency Medicine (EM), how rural doctors grade their own ability to respond to emergencies and evaluate their Continuous Medical Education (CME) within the field of EM. MATERIALS AND METHODS: In this descriptive cross-sectional study, all rural general practitioners (GP) in Iceland with at least two years of experience post foundation training and who practiced at least a quarter of every year outside the capital area were surveyed using an electronic questionnaire. T-test and qi-square test were used for analysis and significance determined if p<0.05. RESULTS: The survey was sent to 84 doctors with 47 (56%) completing the survey. Over 90% of the participants reported having completed a course in Advanced Life Support (ALS) but only 18% had completed a course in prehospital EM specifically designed for this group of doctors. Over half of the participants considered themselves to have good training to perform 7 out of 11 surveyed emergency procedures. Over 40% of participants considered it necessary to improve their CME in 7 out of 10 categories of EM. The majority of rural GPs considered shortage of doctors in the rural environment a significant factor limiting their CME. CONCLUSIONS: The majority of rural doctors in Iceland consider themselves to have a good training to provide initial EM care in their community. Efforts to improve their training in this field of medicine should focus on scene safety and working in the prehospital setting, pediatrics, labor and deliveries and gynecological emergencies. Rural doctors need to have access to appropriate EM training courses.

[Emergency Department visits due to firework accidents in the Reykjavik capital area from 2010 to 2022].

BACKGROUND: Public use of fireworks is widespread in Iceland, and unfortunately associated with injuries. No prior comprehensive research has been done on firework accidents in Iceland. The goal of this study was to gather information about the extent, cause, and impact of firework accidents in the Reykjavik capital area. METHODS: Text search was conducted in medical records to find visits to the Emergency Department (ED) resulting from fireworks accidents over the period December 2010 to January 2022. Medical records were reviewed for details of events and injury. RESULTS: Over the period 248 patients came to the ED after a firework related injury, 73% male. The age range was from 9 months to 79 years of age. Children were 114, 12 were younger than 6 years. There where overall 54 secondary accidents. In total 96 (39%) accidents were traced to a faulty firework. Rockets caused the most accidents 56 (23%), cakes 43 (17%) and handheld candles 32 (13%). Type of firework was not reported in 62 (25%) cases. 157 sustained a burn injury, of which 104 where on hands. Eye injury was found on 67 patients and 97 individuals had open wounds. 22 where admitted to the hospital for a total of 91 days. Nobody died but at least 13 sustained permanent physical impairment due to fireworks. CONCLUSIONS: Over the past decade, 21 patients on average presented to the ED annually with firework injury. 73% of those injured by fireworks are male. Children make up one half of the injured and one child 5 years of age or younger sustains a firework injury every year on average. Preventive measures against firework accidents should be expanded and more restrictive regulations on their use should be considered.

[Evaluation and management of wilderness injuries and acute illness in Iceland during the years 2017-2018].

INTRODUCTION: In Iceland, wilderness search and rescue services are provided by volunteer members of the Icelandic association for search and rescue (ICE-SAR). The rescue teams respond to about 1200 calls every year, with a significant proportion of them involving injured and sick individuals. No previous studies have been done on the service provided by ICE-SAR teams. The aim of this study was to obtain information about the health services provided by ICE-SAR in Iceland. MATERIAL AND METHODS: Data was obtained from the ICE-SAR's and the National emergency call service's (112) databases. Cases that occurred during the years 2017 and 2018 that required transfer and treatment at a health clinic or hospital were included in the study. All cases with no involvement of sick or injured and minor injuries managed on scene without tranport were excluded. Treatment on scene and during transport and preliminary diagnosis made by ICE-SAR teams was reviewed. The medical report at each treating medical facility in Iceland was reviewed for treatment provided and final diagnosis. RESULTS: A total of 189 operations with 239 individuals were included in the study. A majority of the operations were recorded in the South region of Iceland. The average age of individuals was 44,4 years, just over half of cases involving men. Accidents accounted for 86% of all cases where the most common incident was a fall resulting in lower extremity injury. Cardiac disease was the most common cause for acute medical illness. On-scene treatment and use of equipment was not recorded in over 70% of cases. CONCLUSION: The ICE-SAR teams provide health care on regular basis, most commonly after accidents involving the lower extremities. Illness treated by the ICE-SAR volunteers most commonly involves cardiac symptoms. Documentation of on-site treatment and equipment use is incomplete.

[Utility of serum tryptase in Emergency Department patients with possible anaphylaxis].

Background Diagnosing anaphylaxis is often straightforward but can be challenging if the presentation is atypical. In patients with atypical symptoms suspected to be due to an acute allergic reaction, s-tryptase can give additional diagnostic information. Measuring s-tryptase is also helpful in diagnosing mastocytosis. Obtaining s-tryptase levels has been done in the emergency department (ED) at Landspitali since 2011. The aim of this study was to evaluate the benefit of obtaining s-tryptase levels in the ED. Methods With institutional review board approval, all cases where s-tryptase level was obtained in ED patients from 2011-2018 were retrospectively reviewed. A database was collected including information on patient demographics, presenting symptoms, treatment, diagnosis, s-tryptase level and follow up. Results A total of 214 patients had a s-tryptase level measured. Serum tryptase was elevated (>12 µg/L) in 36 cases. Females were 131 and average age 40.6 years. Of the patients, 86.4% had skin or mucosal symptoms, 48.1% cardiovascular symptoms, 49.5% respiratory symptoms and 36.0% had gastrointestinal symptoms. An allergist reviewed 126 returning patients and 65 were considered to have had an episode of anaphylaxis. Of those 65 were 4 patients which did not meet the diagnostic criteria for anaphylaxis but had raised s-tryptase levels. Sensitivity of s-tryptase measurement was 40.9% and specificity 97.1%. Conclusions Obtaining a s-tryptase level from ED patients with possible anaphylaxis seems to be useful in atypical cases. The measurement is specific but not sensitive. No cases of mastocytosis were identified in the patient cohort.

[Emergency department visits in Reykjavik for electric scooter related injuries during the summer of 2020].

INTRODUCTION: Electric scooters have become popular in Iceland. The aim of the current study was to gather data on the incidence, causes, and severity of injuries due to the use of electric scooters in the Reykjavik area during the summer of 2020.   MATERIAL AND METHODS: Individuals presenting to the Emergency Department (ED) at Landspitali between June 1 and August 31 were asked about the location and cause of accident, use of protective equipment, and use of recreational drugs and alcohol. Diagnosis and treatment data was gathered from hospital records.   RESULTS: During the study period, 149 individuals presented with electric scooter injuries,  on average 1.6/day. Patients' age ranged between 8 and 77 years, and 45% were younger than 18 years of age. In 60% of cases the cause of accident was that the patient was riding too fast, lost balance, or uneven road surface. Seventy-nine percent of children reported using a helmet, compared to only 17% of adults. No children reported having been under the influence of alcohol or recreational drugs at the time of the accident, compared to 40% of adults who reported that they were intoxicated. Fractures were diagnosed in 38% of patients, 6% needed hospital admission, but no patient suffered serious injury.   CONCLUSION: During the summer of 2020, one to two individuals were injured daily in the Reykjavík capital area while using electic scooters, but no serious injuries occurred. Preventive measures to decrease injury rate from the use of electric scooters should focus on infrastructure, encourage helmet use, and education on the risk of injury associated with operating electric scooters while intoxicated.

Effect of replacing ambulance physicians with paramedics on outcome of resuscitation for prehospital cardiac arrest.

INTRODUCTION: Limited evidence suggests that the presence of a prehospital physician improves survival from cardiac arrest. A retrospective study is undertaken to examine this question. In Reykjavik, Iceland, prehospital physicians on ambulances were replaced by emergency medical technicians (EMTs) in 2007. The aim of this study is to compare the outcome of prehospital resuscitation from cardiac arrest during periods of time with and without prehospital physician involvement. METHODS: All cardiac arrests that underwent prehospital resuscitation by emergency medical systems between 2004 and 2014 were included. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (ROSC). Subgroup analyses were performed according to the type of cardiac arrest. RESULTS: A total of 471 cardiac arrests were included for analysis, 200 treated by prehospital physicians from 2004 to 2007 and 271 treated by EMTs from 2008 to 2014. The overall rate of survival to hospital discharge and ROSC was 23 and 50% during the study period. No significant difference was observed in the rate of survival to hospital discharge [25 vs 22%, difference 3% (95% confidence interval (CI): 11-5%)] or ROSC [53 vs 47%, difference -6% (95% CI: 15-3%)] between these two time periods. In the subgroup of patients with pulseless electrical activity, survival to hospital discharge did not differ between the two periods, but the rate of ROSC was higher in the 'physician period' [50 vs 30%, difference -20% (95% CI: -40 to -1%)]. CONCLUSIONS: The presence of a prehospital physician on the ambulance was not found to result in a significant improvement in survival or ROSC after cardiac arrest compared to care by EMTs. Patients with pulseless electrical activity experienced an increase in ROSC when a physician was present but without improvement in survival to hospital discharge.

Emergency medicine for 25 Years in Iceland - history of the specialty in a nutshell.

After the early implementation of Emergency Medicine (EM) 25 years ago, Iceland became the first Nordic country to nationally realize the benefits of this specialty. However, the road has been rocky as in many other countries. The early years of EM in Iceland were characterized by a significant shortage of resources, particularly a lack of medical staff dedicated to EM and properly trained for the services required. The main task for the first couple of decades was to build the infrastructure of an operational emergency department based primarily on the model of EM. Although these efforts eventually led to a critical number of specialists becoming certified in EM, recruiting more people remains a priority in order to fully meet the need for specialty trained emergency physicians in Iceland. A key step towards achieving this goal was the initiation of a two-year residency program for specialty training in EM in year 2002. The program was based on a curriculum produced by the Icelandic Society for Emergency Medicine, which had been founded in year 2000. This training program is currently being redeveloped and the curriculum of the Royal College of Emergency Medicine in the UK will be adopted for use in Iceland. Another important milestone was the appointment of the first faculty member dedicated to EM at the University of Iceland. This created an opportunity to teach medical students EM and advance training at the graduate level. Also, conditions for scientific research in EM have been improved, following the establishment of an EM research institute in 2010.Other Nordic countries may be able to benefit from lessons learned and experiences gained from the development of emergency medicine in Iceland during the past quarter of a century.

[Reduction of shoulder dislocation with the Cunningham method].

INTRODUCTION: The Cunningham technique has been shown to be an effective and simple method to reduce a dislocated shoulder. It is based on the theory that the humeral head remains outside the glenoid fossa due to tension in the long biceps tendon. In the beginning of 2013 doctors at the emergency department in Landspitali University Hospital (LUH) in Reykjavik were instructed in the Cunningham method for reduction of anterior dislocation without sedation. The goal of this retrospective study was to evaluate the impact of its induction with regards to number of attempts, successful relocations, sedation, use of analgesics and length of stay in the ED. MATERIAL AND METHODS: We searched our electronic database for patients coming to the ED in LUH in 2012 and 2013 with anterior shoulder dislocation. Information was obtained on age and gender, the ED length of stay, first to fourth attempted methods of reduction, medications given for pain relief and sedation and whether this was the first dislocation or not. We used descriptive statistics and comparing the two groups we used independent sample t-test or chi-square to calculate the p-value. RESULTS: During the study period, a reduction was attempted on 190 patients with a shoulder dislocation with 95% of dislocations successfully reduced in the ED. The proportion of patients on which the Cunningham method was applied on first attempt increased from 1% to 27% between years. Average number of attempts was 1.15 in the first year and 1.38 the second year (p = 0.002). The proportion of successful first attempts fell from 81.6% to 66% (p = 0.016) but successful relocation in the emergency department after all attempts was 93.1% and 97.1%, respectively (p = 0,305). The duration of treatment was similar between years or 226 and 219 minutes (p = 0,839). Sedation ratio decreased from 85.1% to 73.8% (p = 0.024) and use of analgesics was similar between years, 70.6% and 69.6% (p = 0.843). CONCLUSION: Induction of the Cunningham method resulted in a significant reduction in the need for sedation. It reduced the rate of successful relocations in the first attempt and increased the number of attempts to but had no effect on the length of stay in the emergency room or the overall rate of successful relocations. Key words: Cunningham, shoulder, dislocation, reduction Correspondence: Hjalti Mar Bjornsson hjaltimb@landspitali.is.

[Incidence of Bicycle injuries presenting to the Emergency Department in Reykjavik 2005-2010].

INTRODUCTION: Bicycling has become increasingly popular in Iceland. Official registration of bicycle accidents is based on police reports. As minor accidents are often not reported to the police, these accidents may be underreported in police records. The aim of this study was to examine the epidemiology of bicycle related accidents in patients seeking medical assistance at the Emergency Department (ED) at Landspitali-University Hospital, Reykjavik (LUH), Iceland. MATERIALS AND METHODS: This retrospective cohort study was conducted at the ED at LUH, Iceland from January 2005 to December 2010. All medical files were reviewed and sex, age, year and month of accident/injury, helmet wearing, ICD-10 diagnosis, severity of injury according to the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) recorded. The rate of hospital admission was examined with length of stay, Intensive Care Unit admission, use of medical imaging and operative treatment. RESULTS: A total of 3472 patients presented to the ED with bicycle related accidents , 68.3% men and 31.7% female. The average age of patients was 22,6 years (1-95 years). Most are injured during recreational activities (72.4%) and in residence areas (45,7%). Most injuries occurred during May-September (71.4%). Data on counterparty was missing in 74.9% of cases. The cause of accident was in 44.0% a low fall or jump. The upper extremity was injured in 47.1% cases. A majority of the patients (65.6%) had a mild injury (ISS≤3points) and 29.3% had a moderate injury (4-8 points). No fatalities were found during the study period. Use of helmets was only recorded in 14.2% of cases. In total 124 patients were admitted during the period where the mean time of admission was 5 days. CONCLUSION: The incidence of bicycle injuries increased during the study period but appears to have increased less than the number of bicyclists. Injuries are more frequent among males and the majority are of a young age. The accidents usually occur during the spring and summer. Most injuries are minor but 3.6% required admission. Department of Emergency Medicine, The National University Hospital of Iceland1, Icelandic Transportation Safety Board2, Faculty of Medicine, University of Iceland3 KEY WORDS: bicycle accident, emergency department, helmet, injury. Correspondence: Hjalti Mar Bjornsson, hjaltimb@landspitali.is.

[Results of pre-hospital cardiac resuscitation in the Reykjavik area 2004-2007]. / Árangur endurlífgunartilrauna utan spítala a Reykjavíkursvæðinu árin 2004-2007.

INTRODUCTION: In the Reykjavik area, a physician staffed ambulance -responded to cardiac arrests from 1982-2007. The aim of this study was to assess the outcome of attempted pre-hospital cardiac resuscitations in the period from 2004-2007 and compare to previous studies. MATERIAL AND METHODS: All cases of attempted prehospital resuscitations in cardiac arrests of presumed cardiac etiology. Data was gathered according to the Utstein template. RESULTS: Of a total of 289 cases in cardiac arrest, resuscitation was attempted in 279 and 200 of those were presumed to have a cardiac etiology. Men were 76% of the patients and the average age was 67.7 years. Average response time was 6.3 min. One hundred and seven (54%) survived to hospital admission and 50 (25%) survived to discharge compared to 16-19% in previous studies (p=0.16). The presenting rhythm was ventricular fibrillation/ventricular tachycardia (VF/VT) in 50% of the cases, 30% was in asystole and 20% in pulseless electrical activity (PEA). Of those admitted to intensive care unit/ department and had ventricular fibrillation on the first rhythm strip 70% were discharged during 2004-2007 compared to 49% during 1999-2002 (p=0.01). Bystander CPR was provided in 62% of witnessed cases compared to 54% in a previous study (p=0.26). One hundred and twenty (60%) were witnessed cases of which 37 (31%) survived to hospital discharge compared to 5 (8%)of non witnessed cases (p<0.01). CONCLUSION: One in every four cardiac arrest patients in the Reykjavik area survives to discharge. This is similar to previous studies in the area (16-19%) and high compared to international studies 3-16%. Survival of those admitted to intensive care unit/ department and had ventricular fibrillation on the first rhythm strip was significantly higher compared to previous studies. Survival was found to be significantly higher if the cardiac arrest was witnessed.

[Emergency ultrasound for trauma]. / Averkaomun.

The use of ultrasound is now widespread within the field of Emergency Medicine. The availability of lightweight and relatively cheap ultrasound devices has enabled clinicians to obtain more detailed information about the condition of acutely ill and injured patients than can be done with a clinical exam only. This paper discusses the standardized E-FAST exam for trauma; the technical details of the exam and the reliability of the information gained by each of it's components. Other advanced use of ultrasound for evaluation of trauma patients is introduced. Investing in the equipment and physician training to provide emergency ultrasound evaluation of injured and acutely ill patients in Iceland may be a relatively inexpensive way to improve patient care.

Physician experience in addition to ACLS training does not significantly affect the outcome of prehospital cardiac arrest.

BACKGROUND: Little data exists on whether the physicians' skills in responding to cardiac arrest are fully developed after the advanced cardiac life support (ACLS) course, or if there is a significant improvement in their performance after an initial learning curve. OBJECTIVE: To estimate the effect of physician experience on the results of prehospital cardiac arrests. MATERIALS AND METHODS: Prospective data were collected on all prehospital resuscitative attempts in the area by ACLS-trained ambulance physicians. RESULTS: Of 232 attempted cardiac resuscitations, 96 (41%) patients survived to hospital admission and 44 (19%) were discharged alive. A group of 39 physicians responded to from one up to 29 cases with a mean of four cases. Physicians responding to five or fewer cases had a trend to fewer patients surviving to admission compared with those responding to six or more (36 vs. 45%, P=0.31) but no difference was found on survival to discharge (19 vs. 20%, P=0.87). CONCLUSION: In this study, resuscitative experience of the physician did not have a significant effect on survival suggesting that experience does not significantly add to the current ACLS training in responding to ventricular fibrillation/ventricular tachycardia. More studies are needed.

[Allergy and skin infection after use of temporary henna tattoo--case report]. / Ofnaemi og húdsýking eftir notkun á hennahúdflúri--sjúkratilfelli.

We describe a case of a 10 year old boy who developed an contact dermatitis to black henna tattoo. Sixteen days later he was brought to the emergency department because of an presumed superinfection by S. aureus. The infection was successfully treated with dicloxacillin and the allergic reaction with bethametasone ointment and tablets. The use of pure henna is legal but has been proven to be harmful in animal experiments. Para-phenylendiamine (PPD) has been mixed with henna to achieve a darker colour and to decrease the treatment time and is well known to cause allergic reactions.

Converted charter plane for mass transport of patients after a tsunami.

After a tsunami in the Indian Ocean in December 2004, thousands of injured tourists were stranded far away from home. To transport injured Scandinavians and their relatives back to Sweden, a standard Icelandic charter plane was altered for the mission in 2 days. Orthopedic injuries and aspirations were the predominant injuries among patients transported, but all had received advanced care in Thailand. The transport to Sweden was uneventful. The possibility of including charter planes in plans for mass transport of injured patients in disaster preparedness is stressed. For a given incident, a detailed checklist can facilitate gathering vital information to ensure adequate equipment and patient care. The lessons from the preparation of the plane and the mission are reported.

[Prehospital cardiac life support in the Reykjavík area 1999-2002]. / Endurlífgunartilraunir utan sjúkrahúsa á höfudborgarsvaedinu 1999-2002.

OBJECTIVES: A physician manned ambulance has provided advanced resuscitation service in the Reykjavík area for over 20 years. Out of hospital resuscitation since 1982 has been done with average response time of 4.6-4.9 minutes, the survival rate to hospital admission has been 31-40% and survival to hospital discharge 16-17%. In the years preceding this study, several changes were done in the service; the service area was enlarged, dispatch was centralized to one emergency number, the training of EMT s and physicians was improved and a two-tier rendezvous system was adopted. Cell phone coverage reached over 90% of the population. The study was done in 1999-2002 with the objective to: 1. measure the results of attempted prehospital resuscitations for cardiac diseases in the area, 2. to monitor the effect of bystander response, 3. to estimate the effect of changes in the service prior to the study period. MATERIALS AND METHODS: A ambulance staffed with EMTs and one with a physician were dispatched to all possible cases of cardiac arrest. Resuscitation was attempted using the AHA guidelines for resuscitation. Prospective data was collected following the Utstein template recorded by the physician on call. RESULTS: A total of 319 resuscitative attempts were made during the years 1999-2002, excluding hanging, SIDS, drowning, suicide, trauma, internal bleeding and other diseases, a total of 232 arrests were considered of cardiac origin giving an incidence of 33/100,000/year. The average response time was 6,1 min. Of 232 cardiac resuscitation attempts 140 patients (60%) were in VF/VT, 53 (23%) in asystole and 39 (17%) in other rhythms. Ninety-six (41%) of all patients survived being admitted to hospital ward and 44 (19%) survived to discharge with 39 being alive at 12 months. Of patients in VF/VT, 79 (56%) survived to hospital admission and 39 (28%) to hospital discharge. Resuscitation was more successful in cases of witnessed arrest and if CPR was attempted by bystanders. CONCLUSION: Despite various changes in the EMS system, the results of resuscitative attempts are similar to previous studies in the area but an increased proportion of survivors is left with neurological damage. In 54% of the cases COR was performed by bystanders. Response time needs to be shortened and CPR training increased.

[The new international guidelines for cardiopulmonary resuscitation and emergency cardiovascular care]. / Nýjar althjódlegar leidbeiningar um endurlífgun.

Recently the American Heart Association and the European Resuscitation Council published new guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. These new guidelines are the result of extensive review of the scientific literature in this field by The International Liason Committee on Resuscitation. There are some important changes in the new guidelines with a major emphasis on the importance of basic life support, especially chest compressions. The guidelines also promote early defibrillation while the role of pharmacologic therapy during cardiopulmonary resuscitation is not as clear. This article discusses the highlights of the new guidelines.