When health care sickens the health care worker: Commentary on Park et al. (2023).

In their survey, Park and colleagues (2023) reported that many health care and hospital workers perceived that their safety was not a priority during the COVID-19 pandemic, with 33.9% of responders feeling betrayed by institutional leaders. Employees of the health care system reported being viewed more as servants than specialists during the pandemic, and they noted that critical assessment and the expression of one's own opinion were unwelcome (Lederer, 2023). A lack of epidemiologic knowledge was compensated with the inflexible strategy of a hierarchical system. Opting out of testing and vaccination justified exposure, discrimination, and humiliation. Paternalism, a lack of esteem, and complete exhaustion further contributed to the physical and mental health toll of the pandemic on health care and hospital workers.

Arterial Occlusion Effectiveness of Space Blanket‒Improvised Tourniquets for the Remote Setting.

INTRODUCTION: Control of severe extremity hemorrhage by tourniquet can save lives. In remote areas or in mass casualty incidents with multiple severely bleeding victims, lack of conventional tourniquets may make it necessary to improvise tourniquets. METHODS: Occlusion of the radial artery and delayed onset of capillary refill time resulting from windlass-type tourniquets were experimentally investigated by comparing a commercial tourniquet and a space blanket‒improvised tourniquet with a carabiner as a rod. This observational study was conducted on healthy volunteers in optimal application circumstances. RESULTS: Operator-applied Combat Application Tourniquets were deployed more swiftly (27 s, 95% CI: 25.7-30.2 vs 94 s, 95% CI: 81.7-114.4) and achieved 100% complete radial occlusion compared with improvised tourniquets, as assessed by Doppler sonography (P<0.001). When space blanket‒improvised tourniquets were used, traces of radial perfusion persisted in 48% of the applications. In Combat Application Tourniquets, capillary refill times were significantly delayed (7 s, 95% CI: 6.0-8.2 vs 5 s, 95% CI: 3.9-6.3) compared with those when using improvised tourniquets (P=0.013). CONCLUSIONS: Improvised tourniquets should be considered only in dire circumstances with uncontrolled extremity hemorrhage and when no commercial tourniquets are available. Complete arterial occlusion was achieved in only half of the applications using a space blanket‒improvised tourniquet when a carabiner was used as a windlass rod. The speed of application was inferior to that for Combat Application Tourniquets. Similar to Combat Action Tourniquets, the correct assembly and application of space blanket‒improvised tourniquets on upper and lower extremities have to be trained. TRIAL REGISTRATION: ClinicalTrials.gov identifier: BASG No.: 13370800/15451670.

Detecting Hexafluoroisopropanol Using Soft Chemical Ionization Mass Spectrometry and Analytical Applications to Exhaled Breath.

Here we explore the potential use of proton transfer reaction/selective reagent ion-time-of-flight-mass spectrometry (PTR/SRI-ToF-MS) to monitor hexafluoroisopropanol (HFIP) in breath. Investigations of the reagent ions H3O+, NO+, and O2+• are reported using dry (relative humidity (rH) ≈ 0%) and humid (rH ≈ 100%)) nitrogen gas containing traces of HFIP, i.e., divorced from the complex chemical environment of exhaled breath. HFIP shows no observable reaction with H3O+ and NO+, but it does react efficiently with O2+• via dissociative charge transfer resulting in CHF2+, CF3+, C2HF2O+, and C2H2F3O+. A minor competing hydride abstraction channel results in C3HF6O+ + HO2• and, following an elimination of HF, C3F5O+. There are two issues associated with the use of the three dominant product ions of HFIP, CHF2+, CF3+, and C2H2F3O+, to monitor it in breath. One is that CHF2+ and CF3+ also result from the reaction of O2+• with the more abundant sevoflurane. The second is the facile reaction of these product ions with water, which reduces analytical sensitivity to detect HFIP in humid breath. To overcome the first issue, C2H2F3O+ is the ion marker for HFIP. The second issue is surmounted by using a Nafion tube to reduce the breath sample's humidity prior to its introduction into drift tube. The success of this approach is illustrated by comparing the product ion signals either in dry or humid nitrogen gas flows and with or without the use of the Nafion tube, and practically from the analysis of a postoperative exhaled breath sample from a patient volunteer.

Rescue Blankets as Multifunctional Rescue Equipment in Alpine and Wilderness Emergencies-A Narrative Review and Clinical Implications.

The utilization of rescue blankets in pre-hospital emergency medicine exceeds protection from hypothermia and enhanced visibility by far. In this narrative review, we focus on emphasizing the alternative applications of these fascinating multifunctional tools in the pre-hospital setting. A literature search in PubMed® and Web of ScienceTM yielded 100 results (last update was on 8 July 2022), a total number of 26 of which were included in this narrative review. Nine articles assessing alternative functions of rescue blanket were further evaluated and described in more detail. In addition, we performed various experimental and observational trials to test the functionality of rescue practice in mountain emergency medicine. Newly fabricated rescue blankets proved to possess impressive robustness. We evaluated rescue blankets in their applicability to not only protect from hypothermia, but also as practical tools to treat catastrophic hemorrhage and bleeding limbs, to perform open pneumothorax chest seals in sucking chest wounds, to prevent damage to unprotected eyes on the glacier and as alternative instruments for transportation in the inaccessible areas. Rescue blankets are important rescue equipment in alpine and wilderness emergencies with multifunctional applications, and must be part of every personal medical kit.

Electromagnetic Interference from Heated Gloves May Compromise Avalanche Transceiver Function.

INTRODUCTION: Rapid location of avalanche victims by companions using avalanche transceivers is of utmost importance to prevent asphyxiation. The objective was to determine whether electromagnetic interference from heating elements in gloves worn by rescuers or victims can impair the receiving or transmitting function of avalanche beacons. METHODS: Commercially available heated gloves from 3 different manufacturers were examined during a simulated search with 3 common brands of avalanche transceivers. Distance to target beacon at first signal detection and accuracy of direction to target, as indicated by the arrow from the direction indicator, were evaluated. RESULTS: Preliminary tests showed that transmitting and receiving signals are degraded by electromagnetic interference caused by rectangular pulses emitted by activated heating elements. Field tests revealed significantly reduced distances of first signal detection when heated gloves were turned on near receiving avalanche transceivers (P<0.001; Wilcoxon signed-rank test). Decreased distance to target beacon ranged between 1.9 m (5%) and 41.5 m (94%) at first detection, depending on the avalanche transceiver used. CONCLUSIONS: Avalanche transceivers are susceptible to electromagnetic interference from gloves with electric heating elements. We do not recommend using heated gloves when performing a transceiver search for avalanche victims because it can lead to a delay in rescue.

Thin foil body-shield resuscitation barrier device to protect from blood: an experimental study.

In times of collective concern about pandemics, body-shield resuscitation barrier devices are more and more considered to protect against transmission of different pathogens between rescuers and patients. The objective of this experimental study was to investigate the characteristics of blood drops dispersed on the surface of four different foils suitable for blanketing patients during resuscitation. We analyzed run-off characteristics of blood stains depending on surface properties of polyvinyl chloride, polyethylene, polyethylene terephthalate and aluminum-coated polyethylene terephthalate. Confocal fluorescence microscopy revealed less cellular density and lack of fibrin networks in blood stains on the four foil surfaces than on paper towel. Delayed clotting went along with larger areas of contamination indicating a greater likelihood of coming into contact with potential germs but a smaller chance of contracting an infection. Space blankets as obligatory components of first aid kits are readily available for rescuers and serve as a mechanical barrier between rescuers and patients during resuscitation.

[Effects of automated external defibrillators on hands-off intervals in lay rescuers]. / Einfluss verschiedener automatisierter externer Defibrillatoren auf die Hands-off-Intervalle von Ersthelfern.

Background: Survival chances after out-of-hospital cardiac arrests caused by hyperdynamic electric cardiac rhythms can be significantly improved by early defibrillation with automated external defibrillators (AEDs). As postulated in international guidelines, the resulting hands-off intervals should not exceed 10 s. Objectives: We investigated delay in onset of chest compressions and the length of hands-off intervals during defibrillation associated with the application of AEDs. Materials and methods: In a prospective, randomized, single-blinded observational study, the resuscitation efforts by first year medical students were analyzed in different emergency scenarios on manikins. Delay in onset of chest compressions and the length of hands-off intervals between voice prompts from four conventional devices were compared during shockable and nonshockable rhythms. Satisfaction with the device, difficulties with the application, and suggested improvements were assessed by questionnaire. Results: In a total of 70 applications, the start with thoracic compressions was delayed by a mean of 115 s. On average, the first shock was administered after 125 s in shockable heart rhythms. Perishock pauses of less than 10 s were achieved with none of the tested devices. Hands-off intervals during defibrillation differed significantly between the devices (p < 0.001). Improvements were suggested regarding marking, voice prompts, and electrodes. Conclusions: Perishock pause of less than 10 s was not achieved with any of the tested devices. Shortened and more precise voice prompts as well as more clearly arranged labeling and layout of pads are needed to simplify application, reduce delayed onset of chest compressions and shorten hands-off intervals.

Rescue blankets as multifunctional rescue equipment in alpine and wilderness emergencies: a commentary.

Emergency applications of rescue blankets go far beyond protection from hypothermia. In this review alternative applicabilities of these remarkable multifunctional tools were highlighted. Newly fabricated rescue blankets prove impressive robustness. The high tensile strength along with its low weight enable further applications, e.g. immobilization of injured extremities, splinting, wound dressing, a makeshift chest seal in sucking chest wounds, amongst others. Furthermore, the foil can be used as a vapour barrier, as eye protection and it can even be used to construct a stopgap bivouac sack, as alternative tool for transportation in the remote area and a wind shield or a water reservoir in the wilderness. During search-and-rescue missions the light reflection from the gold surface enhances visibility and increases the chance to be found. Rescue blankets are essential parts of first aid kits and backpacks in alpine and wilderness environment with multifunctional applicabilities. In this commentary to a review we want to evaluate the numerous applicabilities of rescue blankets in the treatment of emergencies by wilderness medicine and pre-hospital EMS.

Relationship Between Anesthesia Depth and Quality of Seizures in Patients Undergoing Electroconvulsive Therapy: A Prospective Observational Study.

OBJECTIVES: Electroconvulsive therapy under general anesthesia is an established treatment for mood disorders, such as therapy-resistant depression. As most anesthetic drugs used for induction of anesthesia increase the seizure threshold, adequate depth of anesthesia without diminishing the therapeutic efficacy of interventions is crucial. The aim of this study was to investigate whether anesthesia depth as assessed by Narcotrend (NCT) monitoring correlates with maximum seizure quality. METHODS: An observational study was performed in psychiatric patients undergoing multiple interventions of electroconvulsive therapy. Seizure quality of each attendance was assessed evaluating electroencephalogram end point, electromyogram end point, postictal suppression index, the midictal amplitude, and a 3-step overall graduation. Narcotrend was used to assess anesthesia depth according to index-based electroencephalogram findings. Measurements were obtained before induction of anesthesia, before stimulation, and after arousal. Data were analyzed by means of linear mixed models and generalized estimating equations models. RESULTS: A total of 105 interventions in 12 patients were analyzed. Anesthesia depth before stimulation was significantly associated with seizure quality (standardized ß = 0.244, P = 0.010), maximum sustained coherence (ß = 0.207, P = 0.022), and electroencephalogram duration (ß = 0.215, P = 0.012). A cutoff value of 41 or greater versus 40 or less for the NCT index was found appropriate to differentiate between good and less satisfactory overall seizure quality. CONCLUSIONS: Anesthesia depth index assessed by NCT monitoring was positively associated with seizure quality. Narcotrend monitoring may be useful in assessment of optimal anesthesia depth before stimulation.

Rescue Blanket as a Provisional Seal for Penetrating Chest Wounds in a New Ex Vivo Porcine Model.

BACKGROUND: Open pneumothorax after a penetrating thorax trauma is a life-threatening disease with high mortality. An emergency application of a chest seal (CS) allowing the release of trapped air is the optimum initial therapy until surgical chest drainage is available. METHODS: In a newly developed experimental porcine model of open pneumothorax, we tested 3 different materials regarding their applicability for acute treatment of sucking chest wounds in prehospital emergency care, namely a commonly used rescue blanket (RB), plastic foil from a gauze package (packing material), and a commercial CS. RESULTS: An ex vivo open pneumothorax model using a porcine chest wall and a vacuum-assisted drainage system was successfully established. RB segments sized 70 × 100 mm achieved significantly higher rates of successful sealing than plastic foils from a gauze package sized 100 × 100 mm when the devices were applied to the moistened chest wall and fixed on 3 sides (5/5 [100%] vs 0/5 [0%], respectively; P = .002). Loosely fixed RBs efficiently released injected air (10/10 [100%]) and consequently sealed the wound in all cases (10/10). CONCLUSIONS: RBs, applied wet, are appropriate CSs with good occlusive and adherence properties. Fixation on 2 sides of the dressing is sufficient to allow trapped air to exit while providing appropriate sealing of the chest wound. RBs were superior to plastic foils from a gauze package and were seen to function as a potent makeshift CS when no commercial CS is available.

A retrospective analysis of fibrinolytic and adjunctive antithrombotic treatment during cardiopulmonary resuscitation.

Synergistic effects of fibrinolytic and additional antithrombotic treatment during cardiopulmonary resuscitation in out-of-hospital cardiac arrest of assumed cardiac origin were evaluated retrospectively. Data were drawn from electronic files of the physician-staffed Emergency Medical Services Tyrol. During a 22-month observation period 53 adult patients were treated with tenecteplase (mean 7641 IU), 19 (32.1%) of whom received additional antithrombotic treatment with heparin (4000-5000 IU) and acetylsalicylic acid (250-500 mg). Lasting return of spontaneous circulation occurred in four of 34 patients who received fibrinolytic treatment only and in seven of 19 patients with additional antithrombotic treatment (p = 0.037). Four of five patients who were discharged from hospital had received additional antithrombotic treatment during CPR and were in appropriate neurological status (CPC 1). Considering the small sample size in this retrospective study, the argument may be still be made that fibrinolytic and adjunctive antithrombotic treatment during cardiopulmonary resuscitation in out-of-hospital cardiac arrest of assumed cardiac origin may increase the chances for survival.

Barrier resuscitation by lay rescuers during COVID-19 pandemic.

Aerosols generated from chest compressions and ventilation attempts in patients with cardiac arrest may cause airborne infections. Accordingly, the interim international resuscitation guidelines have restricted basic life support by lay rescuers to compression only and the use of an automated external defibrillator during the COVID-19 pandemic. Although these measures may diminish the risk of infection for laypersons, the missing respiratory support can be detrimental for patients with hypoxia-related cardiac arrest. To overcome this shortcoming we want to introduce a special tool that allows ventilation during barrier resuscitation by laypersons. We hypothesize that the application of a device made of a polyvinyl chloride shield with a centrally installed S-shaped ventilation pipe with integrated filter can provide adequate ventilation while concurrently protecting patient and rescuer from airborne agents. Aerosols from air leakage are removed by adhesion and drainage below the barrier. No specific training other than basic life support is needed. We suggest that a tool of this kind be considered essential equipment and stored together with disposable gloves in public access locations.

Accuracy of training blood volume quantification using a visual estimation tool.

BACKGROUND: We investigated whether the use of a specially designed visual estimation tool may improve accuracy in quantifying blood volumes related to surface spreading. METHODS: A prospective, paired-control, single-blinded experimental study was performed at a medical university. Anesthesiologists and emergency medical personnel estimated various blood volumes on surfaces with varying absorptivity (carpet, towel, polyvinyl chloride, wooden flooring) in an experimental setting. We assessed the sensitivity of training blood volume quantification using a self-designed visual estimation tool by comparing the accuracy of visual blood volume estimations before and after practical training with the tool. RESULTS: A total of 352 estimations by 44 participants were evaluated. Accurate estimations improved significantly from pre-training to post-training (P<0.05). The sensitivity of blood volume quantification was 33.0% after training with the visual estimation tool. Estimations did not depend on age, profession, gender or years of the estimator's professional experience. CONCLUSIONS: Training with a visual estimation tool by professional rescuers can improve the estimation accuracy of blood volumes spread on surfaces with varying absorptivity.

Procedural sedation and analgesia for percutaneous trans-hepatic biliary drainage: Randomized clinical trial for comparison of two different concepts.

Procedural sedation and analgesia (PSA) is important during painful dilatation and stenting in patients undergoing percutaneous trans-hepatic biliary drainage (PTBD). A prospective, nonblinded randomized clinical trial was performed comparing different analgesic regimens with regard to the patient's comfort. Patients were randomly assigned to two treatment groups in a parallel study, receiving either remifentanil or combined midazolam, piritramide, and S-ketamine. The primary study endpoint was pain intensity before, during, and after the intervention using the numerical rating scale (0, no pain; 10, maximum pain). The secondary study endpoint was the satisfaction of the interventional radiologist. Fifty patients underwent PTBD of whom 19 (38.0%) underwent additional stenting. During intervention, the two groups did not differ significantly. After the intervention, the need for auxiliary opioids was higher (12.5% vs 7.7%; p = 0.571) and nausea/vomiting was more frequently observed (33.4% vs 3.8%; p = 0.007) in patients with remifentanil than in patients with PSA. Overall, 45 patients (90.0%) needed additional administration of non-opioid analgesics during postinterventional observation. Remifentanil and combined midazolam, piritramide, and S-ketamine obtained adequate analgesic effects during PTBD. After the intervention, medications with antiemetics and long-acting analgesics were more frequently administered in patients treated with remifentanil (EudraCT No. 2006-003285-34; institutional funding).