An Analysis of Referrals Done by Primary Care Centers to Tertiary Care Institutions.

Background and aim Primary care is an important element for every healthcare system around the world. Providing and optimizing the connection between the primary care centers and advanced clinical centers is a key concept for a well-functioning healthcare system. Our aim in this study was to analyze and review the referral data of primary care centers located in Ankara, Türkiye. Materials and methods We collected the entire referral data from the primary care centers, totaling 8,746 patients between January 1, 2019 and December 31, 2023 by using emergency medical services (EMS) transfer in Ankara. Demographic data, call reasons, transfer centers and transfer-related characteristics of the patients were recorded retrospectively, grouped by year, using EMS data. Results Our findings have shown that most of the referrals were made for Turkish citizens with 8,360 (95.6%) (p<0.001). Healthcare centers located in inner city had the most referrals made with 7,087 (81.0%) (p<0.001). Majority of the referrals were made by physicians in family healthcare centers with 6,583 (75.3%) (p<0.001) with chest pain being the most common diagnosis for referral initiation with 1,429 (16.3%) (p<0.001). This was followed by trauma, with 1,172 (13.4%) (p<0.001). Most common cause for trauma was falls with 613 (52.3%) (p<0.001). Conclusion Our data revealed important elements of local referral patterns. According to our data, majority of the referrals were made by inner city healthcare facilities. Family healthcare centers formed most of the referral requests. For this reason, strengthening these centers is important to prevent unnecessary resource use and delays.

Effects of COVID-19 lockdown strategies on emergency medical services.

INTRODUCTION: The aim of this study is to evaluate the change in the number of EMS cases by comparing the lockdown period, the non-lockdown period, and the pre-pandemic period. METHODS: In our study, 3 periods of EMS cases were compared to evaluate the effect of lockdown. The first period (Period A) included in the study was the lockdown period (01-12-2020 and 31-01-2021. The second period (period B) is the period between 01 and 10-2020 and 30-11-2020, where there was no lockdown despite the pandemic. The third period (period C) in the study is the period between 01 and 12-2019 and 31-01-2020 before the pandemic. RESULTS: A total of 120,989 cases in 3 periods were included in the study. It was determined that the highest number of patients were in period C (42,703, 35.3%), while the least was in period A (39,054, 32.2%). On the other hand, it was found that the number of calls was highest in period A (246,200, 35.1%), while the least was in period C (212,267, 30.2%). Response times were longer in the pandemic period than in the pre-pandemic period. Mean talk time were longer during the pandemic period. The most frequent diagnosis in period A (21.6%) and B (42.2%) was COVID-19. The second most frequent disease group in these two periods was cardiovascular diseases. CONCLUSION: While the number of EMS cases decreased during the pandemic period, it decreased even more during the lockdown period. However, the number of calls increased significantly during the lockdown period, and the response times and talk times increased accordingly.

Analysis of Suicide Cases from Ankara Province: A 3-year Emergency Medical Services Experience.

AIM: While the term "completed suicide" refers to suicides that have resulted in death,"suicide attempts" refers to all attempts that do not result in death.Analyzing EMS cases is a reliable method of obtaining data on suicide attempts and completed suicides. We aimed to determine the relationship between the occurrence of cases on weekdays, weekends, public holidays or long holidays and case characteristics. METHODOLOGY: We evaluated EMS data of Ankara Province on completed suicide and suicide attempts including the date range 01.01.2017- 31.12.2019. We evaluated the data in terms of age, gender, mortality at the scene, and suicide method. In addition, we  evaluated the data according to the hour, day, month, season, and year of the cases. We classified the suicide cases according to their occurrence on weekdays, weekends, public holidays or long holidays. RESULTS: During the 3-year period included in the study, Ankara EMS assigned ambulances to a total of 940,546 cases. Of these cases, 8231 (0.875%) were suicide attempts and completed suicides. Suicide attempts were most frequent in males, in the 20-24 age group, in summer, in July, on Sundays, and between the hours 18:00 and 24:00. The most common method in suicide attempts was self-poisoning by drugs. Completed suicides were most frequent in males, in the 30-34 age group, in spring, in May, on Mondays and Tuesdays, and between the hours 18:00 and 24:00. CONCLUSION: We evaluated different characteristics of suicide cases of EMS. In Turkey, there are few studies in the EMS field on this issue. Therefore, we believe that this study will contribute to the epidemiological evaluation of suicides. We hope that results of this study will help to prevent both suicides and suicide attempts.

Prolonged Extracorporeal Membrane Oxygenation Support as a Bridge to Heart Transplant.

Heart transplant is in high demand, but the wait list exceeds 6 months in Turkey. Until a donor heart can be procured, venoarterial extracorporeal membrane oxygenation is an important support option to bridge patients on the wait list or as a rescue therapy for patients with right ventricular failure after implant of left ventricular assist device; it is less expensive than other options, provides benefits such as simple percutaneous insertion, and requires neither sternotomy nor biventricular and respiratory support. We present a case of a patient bridged to transplant with 5 months of extracorporeal membrane oxygenation support.

Brescia-COVID Respiratory Severity Scale (BRCSS) and Quick SOFA (qSOFA) score are most useful in showing severity in COVID-19 patients.

In this study, we compare the predictive value of clinical scoring systems that are already in use in patients with Coronavirus disease 2019 (COVID-19), including the Brescia-COVID Respiratory Severity Scale (BCRSS), Quick SOFA (qSOFA), Sequential Organ Failure Assessment (SOFA), Multilobular infiltration, hypo-Lymphocytosis, Bacterial coinfection, Smoking history, hyper-Tension, and Age (MuLBSTA) and scoring system for reactive hemophagocytic syndrome (HScore), for determining the severity of the disease. Our aim in this study is to determine which scoring system is most useful in determining disease severity and to guide clinicians. We classified the patients into two groups according to the stage of the disease (severe and non-severe) and adopted interim guidance of the World Health Organization. Severe cases were divided into a group of surviving patients and a deceased group according to the prognosis. According to admission values, the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore were evaluated at admission using the worst parameters available in the first 24 h. Of the 417 patients included in our study, 46 (11%) were in the severe group, while 371 (89%) were in the non-severe group. Of these 417 patients, 230 (55.2%) were men. The median (IQR) age of all patients was 44 (25) years. In multivariate logistic regression analyses, BRCSS in the highest tertile (HR 6.1, 95% CI 2.105-17.674, p = 0.001) was determined as an independent predictor of severe disease in cases of COVID-19. In multivariate analyses, qSOFA was also found to be an independent predictor of severe COVID-19 (HR 4.757, 95% CI 1.438-15.730, p = 0.011). The area under the curve (AUC) of the BRCSS, qSOFA, SOFA, MuLBSTA, and HScore was 0.977, 0.961, 0.958, 0.860, and 0.698, respectively. Calculation of the BRCSS and qSOFA at the time of hospital admission can predict critical clinical outcomes in patients with COVID-19, and their predictive value is superior to that of HScore, MuLBSTA, and SOFA. Our prediction is that early interventions for high-risk patients, with early identification of high-risk group using BRCSS and qSOFA, may improve clinical outcomes in COVID-19.

Manual cardiopulmonary resuscitation versus mechanical cardiopulmonary resuscitation: Which one is more effective during ambulance transport?

OBJECTIVES: Although studies in the field of emergency medical services (EMS) generally compare survival and hospital discharge rates, there are not many studies measuring the quality of cardiopulmonary resuscitation (CPR). In this study, we aimed to compare the mechanical chest compression device and paramedics in terms of CPR quality. METHODS: This is an experimental trial. This study was performed by the EMS of Ankara city (capital of Turkey). Twenty (ten males and ten females) paramedics participated in the study. We used LUCAS™ 2 as a mechanical chest compression device in the study. Paramedics applied chest compression in twenty rounds, whereas mechanical chest compression device applied chest compression in another set of twenty rounds. The depth, rate, and hands-off time of chest compression were measured by means of the model's recording system. RESULTS: The median chest compression rate was 120.1 compressions per minute (interquartile range [IQR]: 25%-75% = 117.9-133.5) for the paramedics, whereas it was 102.3 compressions per minute for the mechanical chest compression device (IQR: 25%-75% = 102.1-102.7) (P < 0.001). The median chest compression depth was 38.9 mm (IQR: 25%-75% = 32.9-45.5) for the paramedics, whereas it was 52.7 mm for the mechanical chest compression device (IQR: 25%-75% = 51.8-55.0) (P < 0.001). The median hands-off time during CPR was 6.9% (IQR: 25-75 = 5.0%-10.1%) for the paramedics and 9% for the mechanical chest compression device (IQR: 25%-75% = 8.2%-12.5%) (P = 0.09). CONCLUSION: During patient transport, according to the chest compression performed by the health-care professionals, it was found that those performed by the mechanical chest compression device were more suitable than that performed by the guides in terms of both speed and duration.

Which hematological markers have predictive value as early indicators of severe COVID-19 cases in the emergency department?

Background/aim: Coronavirus 2019 disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a pandemic infectious disease that causes morbidity and mortality. As a result of high mortality rate among the severe COVID-19 patients, the early detection of the disease stage and early effective interventions are very important in reducing mortality. Hence, it is important to differentiate severe and nonsevere cases from each other. To date, there are no proven diagnostic or prognostic parameters that can be used in this manner. Due to the expensive and not easily accessible tests that are performed for COVID-19, researchers are investigating some parameters that can be easily used. In some recent studies, hematological parameters have been evaluated to see if they can be used as predictive parameters. Materials and methods: In the current study, almost all hematological parameters were used, including the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, monocyte/lymphocyte ratio, mean platelet volume to lymphocyte ratio, mean platelet volume to platelet ratio, plateletcrit, and D-dimer/fibrinogen ratio, neutrophil/lymphocyte/platelet scoring system, and systemic immune-inflammation index. A total of 750 patients, who were admitted to Ankara City Hospital due to COVID-19, were evaluated in this study. The patients were classified into 2 groups according to their diagnosis (confirmed or probable) and into 2 groups according to the stage of the disease (nonsevere or severe). Results: The values of the combinations of inflammatory markers and other hematological parameters in all of the patients with severe COVID-19 were calculated, and the predicted values of these parameters were compared. According to results of the study, nearly all of the hematological parameters could be used as potential diagnostic biomarkers for subsequent analysis, because the area under the curve (AUC) was higher than 0.50, especially for the DFR and NLR, which had the highest AUC among the parameters. Conclusion: Our findings indicate that, the parameters those enhanced from complete blood count, which is a simple laboratory test, can help to identify and classify COVID-19 patients into non-severe to severe groups.

Effects of COVID-19 Pandemic on Emergency Medical Services.

INTRODUCTION: In this study, we aimed to analyse the changes that occurred after the COVID-19 pandemic using the data of EMS of Ankara province. MATERIALS AND METHODS: EMS data for the same time interval (March 11-April 24) in the last 3 years (2018, 2019 and 2020) were compared. RESULTS: While the number of calls increased by 90.9% during the pandemic period (from 2019 to 2020), the number of cases increased by 9.8%. Of all cases transported to hospital, 15.2% were suspected of and 2.9% were diagnosed with COVID-19. In the pandemic period, case frequency decreased in the 0-6 age group (-4.1%) and 7-18 age group (-39.9%) while the number of patients in the 19-65 age group (12.9%) and 65+ age group (21.5%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of rural area case frequency. During the pandemic period, case frequency of angina pectoris (-35.2%), myocardial infarction (-45%), acute abdomen (-23.8%) and cerebrovascular diseases (-2.9%) decreased contrary to pre-pandemic period (2019). During the same period, symptoms of fever (+14.1%) and cough (+956.3%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of forensic case frequency (P < .05). In addition, there was a statistically significant difference between these periods in terms of the frequency of patients who died at the scene. CONCLUSION: Although the use of ambulances has increased in the pandemic process, the use of EMS for time-sensitive diseases has decreased.

Role of lung ultrasonography in the diagnosis of COVID-19 patients admitted to the emergency department.

Introduction: In this study, the use of lung ultrasonography (LUS) to diagnosis lung findings was evaluated in patients with suspected COVID-19 who were admitted to the emergency department (ED). Methods: This observational clinical study was conducted in the ED of the Ankara City Hospital during the period April 1-30, 2020. Patients who were admitted to the ED were triaged as COVID-19 infected and who agreed to undergo LUS/LCT (lung computed tomography) were included in the study. Results: Included in the study were 40 patients who had been prediagnosed with COVID-19. Pneumonia was detected with LCT in 32 (80%) patients, while the LUS examination identified pneumonia in 23 patients. The most common finding in LCT was ground-glass opacity (n = 29, 90.6%). Of the 23 patients with pneumonia findings in LUS, 15 (65.2%) had direct consolidation. Among the 32 patients who were found to have pneumonia as a result of LCT, 20 (62.5%) had signs of pneumonia on LUS examination, and 12 had no signs of pneumonia. In addition, 3 patients showed no signs of pneumonia with LCT, but they were misdiagnosed with pneumonia by LUS. The sensitivity of LUS in the diagnosis of pneumonia in the COVID-19 patients was 62.5%, while its specificity was 62.5%. In addition, its positive predictive value was 87.0%, and its negative predictive value was 29.4%. Conclusion: LUS may also be used in the diagnosis of pneumonia in COVID-19 patients because it is a valuable and accessible bedside diagnostic tool.

Transport of awake hypoxemic probable COVID 19 patients in the prone position.

OBJECTIVE: We aimed to investigate the effects of transport with prone position on hypoxemia in hypoxemic and awake probable COVID 19 pneumonia patients. METHODS: Hypoxic and awake patients with probable COVID 19 pneumonia who were referred to the Ankara City Hospital Emergency Department from 1 April to 31 May 2020 were included in this prospective study. Patients were transported in prone position and fixed on the stretcher. During the transport, patients continued receiving 2 l per minute oxygen with nasal cannula. Arterial blood gases were obtained from the patients before and after transport. The transport time was recorded as minutes. The primary outcome of the study is the increase of partial oxygen value in the arterial blood gas of patients after transport. RESULTS: It was found that pO2 and SpO2 end values were statistically significantly higher in the patient group compared to the initial values. In the group with transport duration of more than 15 min, a difference was found between the initial and end values in pO2 and SpO2 parameters similar to the whole group. However, there was no statistically significant difference between the initial and end values in the group with transport duration of 15 min or below. CONCLUSIONS: Awake hypoxemic patients can be transported without complications in prone position during transport. Transports more than 15 min, prone position may be recommended because the partial oxygen pressure of the patients increases.

The Effect of the COVID-19 Pandemic on the Anxiety Level of Emergency Medical Services Professionals.

INTRODUCTION: Healthcare professionals are one of the groups most affected by a pandemic that affects the whole world. This study aimed to determine the anxiety level of emergency medical services professionals in Ankara, Turkey after the emergence of the COVID-19 pandemic. SUBJECTS AND METHODS: In the first part of the survey, the participants of the study were asked about their socio-demographic characteristics and their contact with the COVID-19 patients. In the second part, a survey with 20 questions that determined the state anxiety level derived from the State Anxiety Inventory was performed after obtaining verbal consent. RESULTS: The mean age of the participants was 33.1±6.9, while 52.7% of all participants were males. In this study, the mean STAI Anxiety Score was 50.7±11.6. Anxiety scores were higher in females and those who had family members at risk of COVID-19 infection (p<0.05). The majority of those who had family members at risk of the infection started to stay in guesthouses instead of going home. Participants were worried about transmitting the infection to their family members (p<0.05). They felt more anxious when treating COVID-19 diagnosed or other patients (p<0.05). In addition, they thought that their anxiety level increased in general (p<0.05). CONCLUSION: The COVID-19 pandemic caused an anxiety increase in EMS workers in Turkey. Protecting the physical and mental health of the EMS employees who work at the front line against the COVID-19 pandemic and who have a high risk of infection, and ensuring their efficient work should be the main priority.

Evaluation of inflammatory rheumatic diseases from an emergency medicine perspective.

BACKGROUND: Patients with rheumatological complaints may visit an emergency department (ED) because of an acute attack or complication. Because of the recent increased use of immunosuppressant drugs to treat rheumatic diseases, more patients with these conditions visit the ED with a complaint about an infection. However, there are little data on the ED visits of patients with rheumatological complaints. This study evaluated the ED visits of patients with inflammatory rheumatic diseases. MATERIALS AND METHODS: A total of 2715 patients (1753 females, 962 males) who had been diagnosed with an inflammatory rheumatic disease and followed up at the rheumatology clinic of Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital between April 2014 and April 2018 were included in the study. The demographic, clinical, and laboratory characteristics of the patients were obtained from the hospital patient records. The ED visits of these patients were classified into five triage groups (T1: critical, T2: very urgent, T3: urgent, T4: less urgent, T5: not urgent). RESULTS: Of the 2715 patients, 577 (21.3%) had visited the ED. The three most numerous groups who visited the ED were patients with rheumatoid arthritis (19.8%), ankylosing spondylitis (19.2%), and familial Mediterranean fever (15.9%). Of these 577 patients, 347 (60.1%) were discharged from the ED, 209 (36.2%) were hospitalized in the wards, and 21 (3.6%) were hospitalized in the intensive care unit (ICU). The 3 main reasons for visiting the ED were fever and malaise (n = 152, 26.3%), musculoskeletal complaints (n = 125, 21.7%), and abdominal pain (n = 89, 15.4%). The most numerous group of patients referred by the ED to the wards had vasculitis (n = 38, 17.9%), while the most numerous group of patients referred to the ICU had scleroderma (n = 7, 33.3%). Of the 21 patients who were referred by the ED to the ICU, 16 (76.1%) had respiratory system complaints. Of the 577 patients, 10 (1.7%) died. Eight of the 10 patients (80%) had a rheumatic disease and died after admission to the ICU. The other 2 patients had been diagnosed with pneumonia and myocardial infarction, respectively. CONCLUSIONS: Our study found that visits to the ED by patients with inflammatory rheumatic diseases were classified as urgent or less urgent. Patients with rheumatoid arthritis were the most numerous ED visitors. Vasculitis was the most common cause of hospitalization in the wards and scleroderma was the most common cause of hospitalization in the ICU and death. This suggests that ED physicians should be aware of these patients.

Role of hematological parameters in COVID-19 patients in the emergency room.

Aim: In this study, the roles of biomarkers from a peripheral blood sample in the diagnosis of COVID-19 patients who have visited the emergency room have been evaluated. Materials & methods: Peripheral blood parameters, systemic inflammatory index (SII), neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio were compared in patients with and without confirmed COVID-19 infection. Results: Comparisons made according to real-time PCR test results revealed that while no statistically significant difference was observed between test groups (negative-positive) regarding lymphocyte and platelet lymphocyte ratio values (p > 0.05), a statistically significant difference (p < 0.05) was found between the test groups regarding platelet, hemoglobin, leukocyte, neutrophil, NLR and SII values. Conclusion: Leukocyte, neutrophil, platelet count, NLR and SII values can be used in the diagnosis of COVID-19.

A pandemic center's experience of managing pregnant women with COVID-19 infection in Turkey: A prospective cohort study.

OBJECTIVE: To evaluate the course and effect of coronavirus disease 2019 (COVID-19) on pregnant women followed up in a Turkish institution. METHODS: A prospective, single tertiary pandemic center cohort study was conducted on pregnant women with confirmed or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Positive diagnosis was made on a real-time polymerase chain reaction (RT-PCR) assay of a nasopharyngeal and oropharyngeal specimen. Demographic features, clinical characteristics, and maternal and perinatal outcomes were evaluated. RESULTS: SARS-CoV-2 was suspected in 100 pregnant women. Of them, 29 had the diagnosis confirmed by RT-PCR. Eight of the remaining 71 cases had clinical findings highly suspicious for COVID-19. Ten (34.5%) of the confirmed cases had co-morbidities. Cough (58.6%) and myalgia (51.7%) were the leading symptoms. COVID-19 therapy was given to 10 (34.5%) patients. There were no admissions to the intensive care unit. Pregnancy complications were present in 7 (24.1%) patients. Half of the births (5/10) were cesarean deliveries. None of the neonates were positive for SARS-CoV-2. Samples of breastmilk were also negative for the virus. Three neonates were admitted to the neonatal intensive care unit. CONCLUSION: The clinical course of COVID 19 during pregnancy appears to be mild in the present study.

The effect of meteorological variables on suicide.

We aimed to reveal the relationship between the meteorological variables and suicide rates (completed suicides and suicide attempts) independently of the seasonal cycle and holiday effects. This is an observational retrospective study. We collected the data on age, gender, and suicide method of all suicide cases transferred to hospitals from the scene by emergency medical services as well as those cases in which the victim died on the scene between January 1, 2017 and June 30, 2019. We also collected data on maximum, minimum, and average temperatures (°C), average humidity (%), and average actual pressure (hPa) measured daily in Ankara. The total number of cases due to suicide between the given dates was 6777. The suicide method in 60.1% of the cases was drug poisoning, which was the most common suicide method. Investigating the effect of meteorological variables on suicide cases (suicide attempts and completed suicides), the present study found that after smoothing the effect of the day of the week and seasonality, an increase in the minimum temperature on the day of the application by 1 unit (1°C degree) leads to an increase in the number of suicides by 0.01 point (0.01 ± 0.005, p = 0.046). There was no significant change in the variables other than the minimum temperature. We believe that the results of the present study will contribute to growing body literature about the epidemiology of suicide. We also believe that there is a need for large-scale studies that include individual data to reveal causality.

Quality Comparison of the Manual Chest Compression and the Mechanical Chest Compression During Difficult Transport Conditions.

BACKGROUND: Although there are several studies comparing the quality of manual and mechanical chest compressions, we decided to conduct this study because results of previous studies were not sufficient for us to arrive at a definite conclusion. OBJECTIVE: In this study, our goal was to evaluate the quality of cardiopulmonary resuscitation (CPR) performed manually and by mechanical chest compression device (MCCD) when removing out-of-hospital cardiac arrest patients from their homes via stairs. METHODS: A total of 20 paramedics participated in the study. The patient simulator manikin was moved down the stairs while each of 20 paramedics performed chest compressions, then it was moved down the stairs again 20 times while the MCCD performed chest compressions. Compression depth, compression rate, and hands-on times were recorded and the data were compared. RESULTS: The median chest compression rate was 142.0 compressions/min (interquartile [25th to 75th percentile] range [IQR] 134.9-148.7 compressions/min) for the paramedics and 102.3 compressions/min for the MCCD (IQR 102.2-102.5 compressions/min) (p < 0.01). The median chest compression depth was 25.2 mm (IQR 23.2-30.9 mm) for the paramedics and 52.0 mm for the MCCD (IQR 51.4-52.6 mm) (p < 0.001). The rate of hands-on time for chest compressions performed by the paramedic participants was 92.0% (IQR 86.5-100%). Hands-on rate of the MCCD was 100% (p = 0.09). CONCLUSIONS: In our study, while carrying the patient simulator manikin to the lower floor, it was found that the MCCD achieved high-quality CPR targets recommended by resuscitation guidelines in terms of compression rate, depth, and hands-on-time.