Posttraumatic Stress Responses and Psychological Well-being in Norwegian Medical Helicopter Personnel.

OBJECTIVE: Emergency medical personnel are exposed to multiple stressors, including those of psychological etiologies. The aim of this study was to report the prevalence of anxiety, depression, and posttraumatic stress symptoms in Norwegian medical helicopter personnel and to determine to what degree they report personal growth or deprecation due to exposure to work-related events. METHODS: This was a web-based, cross-sectional survey performed among rescue paramedics and physicians staffing helicopter emergency medical services and search and rescue helicopters between May 5, 2021, and July 5, 2021. Questions included demographic data, the traumatic events exposure index, the Generalized Anxiety Disorder 7 scale, the Patient Health Questionnaire 9 (Depression), the posttraumatic change scale, and the posttraumatic symptom scale. RESULTS: Of the 245 eligible participants, 10 declined to take part and 74 failed to answer, producing a response rate of 66% (72 rescue paramedics and 89 physicians). Of the study population, 3.9 % reported manifest posttraumatic stress disorder symptoms, and 1.9% described moderate to severe depression and anxiety. The majority (76%) described posttraumatic emotional growth because of their work experience. CONCLUSION: Despite exposure to several traumatic stressors, participants reported a lower prevalence of posttraumatic stress symptoms, depression, and anxiety compared with a Norwegian adult population.

The effect of the new rescue helicopters on the rescue service's mission profile. / Nytt redningshelikopters innvirkning på redningstjenestens oppdragsprofil.

BACKGROUND: The change of rescue helicopter type from the Sea King to the SAR Queen has been controversial. Some hospitals can no longer receive rescue helicopters because of the stronger rotor downwash from the SAR Queen. For the same reason, it has been unclear whether the SAR Queen would be able to land near patients for air ambulance missions. The objective of the study was to investigate whether the change of helicopter type has changed the rescue service's mission profile. MATERIAL AND METHOD: Mission data from the first eight months with the SAR Queen at Ørland Air Base (14 May 2021-14 January 2022) were compared with the last equivalent period with the Sea King (14 May 2020-14 January 2021). RESULTS: The number of requests increased from 249 to 349 (40 %) after the introduction of the new rescue helicopter. Response time increased from 11 to 13 minutes (18 %), while the on-scene time remained unchanged at 10 minutes for primary missions and search and rescue missions. The patients' average degree of severity, assessed by NACA scores, remained unchanged at 3.7. The proportion of missions where hoisting of a rescue paramedic or a doctor was required to gain access to the patient remained unchanged. INTERPRETATION: The study showed that the use of the rescue helicopter at Ørland Air Base increased after the phasing-in of the SAR Queen. The service's mission profile remained the same. The unchanged proportion of missions that involved hoisting indicates that suitable landing sites close to the patients were found to the same extent as with the Sea King.

Patients with low-voltage electric shock referred to an Emergency Department. / Pasienter med strømgjennomgang fra lavspenning henvist til et akuttmottak.

BACKGROUND: Patients exposed to electricity are often referred to the Emergency Department, but guidelines differ as to how they should be managed. In this article, we describe patients with low-voltage electric shock in the Emergency Department at St Olav's Hospital, Trondheim University Hospital. MATERIAL AND METHOD: Retrospective data from patients referred to the Emergency Department following low-voltage electric shock (< 1,000 V) in the period 1.1.2012-31.12.2017 (N = 210) were included. RESULTS: The median age was 26 years and 186/210 (89 %) were men. Out of the 210 patients, 165 (79 %) had symptoms following electric shock. Localised pain and chest discomfort occurred in 84/165 (51 %) and 57/165 (35 %) of patients respectively. ECG findings were normal in 168/209 (80 %), and no patients had arrhythmias requiring treatment or elevated troponin T or creatine kinase. No patients had serious complications or died. INTERPRETATION: Low-voltage electric shock did not cause serious arrhythmias or elevated levels of troponin T or creatine kinase. It should be possible to manage asymptomatic patients with normal findings on clinical examination and ECG in a prehospital setting without reducing patient safety.

Patient visits to an emergency department in anticipation of the COVID-19 pandemic. / Pasienttilstrømming i et akuttmottak i påvente av covid-19-pandemien.

BACKGROUND: The Emergency Department in Trondheim has prepared for a large influx of patients infected with the SARS-CoV-2 virus. We conducted a study comparing patients in the Emergency Department in the first weeks of the pandemic in Norway (weeks 11 and 12) with the average number of patient visits. MATERIAL AND METHOD: Data from patients at the Emergency Department of St Olav's Hospital in the period 6 January 2020-22 March 2020 were retrieved from the Emergency Department's database. Logistical patient data concerning patient numbers, chief complaints, length of stay in the Emergency Department, acuity level, isolation status, and treatment level were analysed. RESULTS: In week 12, 331 patients were referred to the Emergency Department, a reduction of 39 % compared with the average of 541 patients in weeks 2-10. There was a general reduction in all patient groups, but particularly those discharged from the Emergency Department. In week 12 there were 56 more patients isolated with suspected/potentially infectious disease (187 %) compared with the average for weeks 2-10, and these patients spent almost two hours longer in the Emergency Department than other patients. INTERPRETATION: There was a reduction in patient visits to the Emergency Department in the first weeks of the pandemic. The percentage of patients isolated for infection control increased, and the time spent in the Emergency Department for these patients was greater than for other patients. The reduction in the inflow of patients is expected to be temporary, and the Emergency Department at St Olav's Hospital expects a large influx of patients with suspected COVID-19 disease.

Description of chest pain patients in a Norwegian emergency department.

OBJECTIVES: Chest pain is one of the most frequent chief complaints in patients admitted to the emergency department (ED). No study has evaluated this patient population in Norway. The aim of the present study was to describe the diagnoses and logistics of chest pain patients admitted to the ED at a Norwegian university hospital. DESIGN: Data were collected from all patients referred to the ED at St. Olav's Hospital-Trondheim University Hospital in 2015. Patients presenting at the ED with a chief complaint of chest pain based on the Rapid Emergency Triage and Treatment System were included in this study. RESULTS: In the study period, 22,403 patients were admitted to the ED. Chest pain was the second most common chief complaint (11%), only exceeded by acute abdominal pain (18%). Among the chest pain patients, 12% had acute coronary syndrome (ACS) and 37% were diagnosed with non-specific chest pain. Gastrointestinal, musculoskeletal, and pulmonary conditions were less common, affecting 6%, 4%, and 4% of the patients, respectively. In total, 90% of the ED chest pain patients were handled by the Clinic of Cardiology. CONCLUSIONS: Chest pain was the second most common chief complaint among patients admitted to the ED, and most patients were handled by the Clinic of Cardiology. More than one-third of the patients received a cardiac diagnosis, but the largest group of patients was discharged with a diagnosis of non-specific chest pain. Other conditions managed by non-cardiac medical specialties were less common.

Real-time forecasting of emergency department arrivals using prehospital data.

BACKGROUND: Crowding in emergency departments (EDs) is a challenge globally. To counteract crowding in day-to-day operations, better tools to improve monitoring of the patient flow in the ED is needed. The objective of this study was the development of a continuously updated monitoring system to forecast emergency department (ED) arrivals on a short time-horizon incorporating data from prehospital services. METHODS: Time of notification and ED arrival was obtained for all 191,939 arrivals at the ED of a Norwegian university hospital from 2010 to 2018. An arrival notification was an automatically captured time stamp which indicated the first time the ED was notified of an arriving patient, typically by a call from an ambulance to the emergency service communication center. A Poisson time-series regression model for forecasting the number of arrivals on a 1-, 2- and 3-h horizon with continuous weekly and yearly cyclic effects was implemented. We incorporated time of arrival notification by modelling time to arrival as a time varying hazard function. We validated the model on the last full year of data. RESULTS: In our data, 20% of the arrivals had been notified more than 1 hour prior to arrival. By incorporating time of notification into the forecasting model, we saw a substantial improvement in forecasting accuracy, especially on a one-hour horizon. In terms of mean absolute prediction error, we observed around a six percentage-point decrease compared to a simplified prediction model. The increase in accuracy was particularly large for periods with large inflow. CONCLUSIONS: The proposed model shows increased predictability in ED patient inflow when incorporating data on patient notifications. This approach to forecasting arrivals can be a valuable tool for logistic, decision making and ED resource management.

Low-voltage electric shock - proposed new recommendations. / Strømgjennomgang fra lavspenning ­ forslag til nye anbefalinger.

We propose new recommendations for the emergency treatment of low-voltage electric injuries (<1 000 volts). A large proportion of these patients can be treated as outpatients.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study.

BACKGROUND: Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times. OBJECTIVE: To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times. DESIGN: This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities. SETTING: Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022. MAIN OUTCOME MEASURES: Prevalence of busy ambulances and differences in response times associated with busy ambulances. RESULTS: The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively. CONCLUSION: Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

Patient visits to the emergency department at a Norwegian university hospital: variations in patient gender and age, timing of visits, and patient acuity.

BACKGROUND: The patient visits to Norwegian emergency departments (EDs) have increased significantly over the last few years. A national evaluation revealed a lack of systematic activity control, resource management and quality improvement. This paper describes some variables in patient visits to an urban Norwegian university hospital. METHODS: The retrospective data were collected from a database (Akuttdatabasen) and included all patients admitted to the main ED at the St. Olav's University Hospital between 1 December 2010 and 1 December 2011. RESULTS: ED visits have increased by 44% over the last decade and show considerable timely variations. Almost 50% of the patients are older than 65 years of age. The rate of patients triaged with the highest acuity level was 11%, but only 1.3% of the patients were admitted to the Intensive Care Unit (ICU). The total admission rate was 89%. CONCLUSIONS: The increase in ED visits to the St. Olav's Hospital in recent years follows the same trend as in other countries. The authors see a slightly higher percentage of high level acuity patients compared with international studies due the general practitioner's intended 'gatekeeper' function. The authors also found a high total admission rate and a low ICU admission rate compared with other countries. These differences cannot be explained solely by differences in the healthcare system in Norway. The cultural and traditional organisation of the Norwegian Health Care System needs to change and this creates an excellent opportunity to improve the competence by establishing emergency medicine as a specialty in Norway.

Comparison of intranasal and intramuscular naloxone in opioid overdoses managed by ambulance staff: a double-dummy, randomised, controlled trial.

AIMS: To measure and evaluate clinical response to nasal naloxone in opioid overdoses in the pre-hospital environment. DESIGN: Randomised, controlled, double-dummy, blinded, non-inferiority trial, and conducted at two centres. SETTING: Participants were included by ambulance staff in Oslo and Trondheim, Norway, and treated at the place where the overdose occurred. PARTICIPANTS: Men and women age above 18 years with miosis, rate of respiration ≤8/min, and Glasgow Coma Score <12/15 were included. Informed consent was obtained through a deferred-consent procedure. INTERVENTION AND COMPARATOR: A commercially available 1.4 mg/0.1 mL intranasal naloxone was compared with 0.8 mg/2 mL naloxone administered intramuscularly. MEASUREMENTS: The primary end-point was restoration of spontaneous respiration of ≥10 breaths/min within 10 minutes. Secondary outcomes included time to restoration of spontaneous respiration, recurrence of overdose within 12 hours and adverse events. FINDINGS: In total, 201 participants were analysed in the per-protocol population. Heroin was suspected in 196 cases. With 82% of the participants being men, 105 (97.2%) in the intramuscular group and 74 (79.6%) in the intranasal group returned to adequate spontaneous respiration within 10 minutes after one dose. The estimated risk difference was 17.5% (95% CI, 8.9%-26.1%) in favour of the intramuscular group. The risk of receiving additional naloxone was 19.4% (95% CI, 9.0%-29.7%) higher in the intranasal group. Adverse reactions were evenly distributed, except for drug withdrawal reactions, where the estimated risk difference was 6.8% (95% CI, 0.2%-13%) in favour of the intranasal group in a post hoc analysis. CONCLUSION: Intranasal naloxone (1.4 mg/0.1 mL) was less efficient than 0.8 mg intramuscular naloxone for return to spontaneous breathing within 10 minutes in overdose patients in the pre-hospital environment when compared head-to-head. Intranasal naloxone at 1.4 mg/0.1 mL restored breathing in 80% of participants after one dose and had few mild adverse reactions.

A cross-sectional study of mental health-, posttraumatic stress symptoms and post exposure changes in Norwegian ambulance personnel.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been shown to be elevated among first responders (Emergency Medical Services, fire service, police force) compared to the general population. Examining the prevalence of mental health issues in a work force with an elevated occupational risk is fundamental towards ensuring their wellbeing and implementing safeguard measures. The goal of this study is therefore to report the prevalence of depression, anxiety, posttraumatic development, and PTSD in Norwegian ambulance personnel. METHODS: This study is a cross-sectional, anonymous, web-based survey (Questback®), performed among operative personnel employed in the Emergency Medical Services in the Regional Health Trust of Central Norway between 18. February and 9. April 2021. The study was sent to 1052 eligible participants. Questions reported demographic data, a traumatic events exposure index, Patient Health Questionnaire-9 (Depression), Generalized Anxiety Disorder-7 scale, Posttraumatic symptom scale (PTSD) and Posttraumatic change scale. RESULTS: The response rate in this study was 45.5% (n = 479/1052). The mean age of respondents was 37.1 years (std. 11.1) and 52.8% (n = 253) were male. Of the respondents, 80.6% (n = 386) were married or had a partner, and 91.6% (n = 439) reported having access to a peer support programme, with 34.9% (n = 167) reporting that they had utilized peer support. In this study, 5% (n = 24) showed a prevalence of manifest posttraumatic stress disorder symptoms, while 8.6% (n = 41) reported moderate to severe depression and 2.9% (n = 14) presented moderate to severe symptoms of general anxiety. Of the respondents, 77.2% (n = 370) reported personal growth because of their work experiences. CONCLUSIONS: This study indicates that Norwegian ambulance personnel report a prevalence of posttraumatic stress symptoms and depression, which is slightly higher for men, and lower for the female proportion in this study, when compared to an adult Norwegian population. The vast majority of respondents reported personal growth because of their work experience, and both the degree of peer support and having a partner seem to influence levels of posttraumatic stress and -development.

REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial.

BACKGROUND: Survival after out-of-hospital cardiac arrest (OHCA) is poor and dependent on high-quality cardiopulmonary resuscitation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be advantageous in non-traumatic OHCA due to the potential benefit of redistributing the cardiac output to organs proximal to the aortic occlusion. This theory is supported by data from both preclinical studies and human case reports. METHODS: This multicentre trial will enrol 200 adult patients, who will be randomised in a 1:1 ratio to either a control group that receives advanced cardiovascular life support (ACLS) or an intervention group that receives ACLS and REBOA. The primary endpoint will be the proportion of patients who achieve return of spontaneous circulation with a duration of at least 20 min. The secondary objectives of this trial are to measure the proportion of patients surviving to 30 days with good neurological status, to describe the haemodynamic physiology of aortic occlusion during ACLS, and to document adverse events. DISCUSSION: Results from this study will assess the efficacy and safety of REBOA as an adjunctive treatment for non-traumatic OHCA. This novel use of REBOA may contribute to improve treatment for this patient cohort. TRIAL REGISTRATION: The trial is approved by the Regional Committee for Medical and Health Research Ethics in Norway (reference 152504) and is registered at ClinicalTrials.gov (reference NCT04596514) and as Universal Trial Number WHO: U1111-1253-0322.

NTNU intranasal naloxone trial (NINA-1) study protocol for a double-blind, double-dummy, non-inferiority randomised controlled trial comparing intranasal 1.4 mg to intramuscular 0.8 mg naloxone for prehospital use.

INTRODUCTION: Intranasal (IN) naloxone is widely used to treat opioid overdoses. The advantage of nasal administration compared with injection lies in its suitability for administration by lay people as it is needless. Approved formulations of nasal naloxone with bioavailability of approximately 50% have only undergone trials in healthy volunteers, while off-label nasal sprays with low bioavailability have been studied in patients. Randomised clinical trials are needed to investigate efficacy and safety of approved IN naloxone in patients suffering overdose. This study investigates whether the administration of 1.4 mg naloxone in 0.1 mL per dose is non-inferior to 0.8 mg intramuscular injection in patients treated for opioid overdose. METHODS AND ANALYSIS: Sponsor is the Norwegian University of Science and Technology. The study has been developed in collaboration with user representatives. The primary endpoint is the restoration of spontaneous respiration≥10 breaths/min based on a sample of 200 opioid overdose cases. Double-dummy design ensures blinding, which will be maintained until the database is locked. ETHICS AND DISSEMINATION: The study was approved by the Norwegian Medicines Agency and Regional Ethics Committees (REC: 2016/2000). It adheres to the Good Clinical Practice guidelines as set out by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use.Informed consent will be sought through a differentiated model. This allows for deferred consent after inclusion for patients who have regained the ability to consent. Patients who are unable to consent prior to discharge by emergency services are given written information and can withdraw at a later date in line with user recommendations. Metadata will be published in the Norwegian University of Science and Technology Open repository. Deidentified individual participant data will be made available to recipients conditional of data processor agreement being entered. TRIAL REGISTRATION NUMBERS: EudraCT Registry (2016-004072-22) and Clinicaltrials.gov Registry (NCT03518021).

The effect of emergency department delays on 30-day mortality in Central Norway.

OBJECTIVE: To assess whether prolonged length of stay in the emergency department was associated with risk of death. METHODS: We analysed data from 165,183 arrivals at St. Olav's University Hospital's emergency department from 2011 to 2018, using an instrumental variable method. As instruments for prolonged length of emergency department stay, we used indicators measured before arrival of the patient. These indicators were used to study the association between prolonged length of emergency department stay and risk of death, being discharged from the emergency department and length of hospitalisation for those who were hospitalised. RESULTS: Mean length of stay in the emergency department was 2.9 hours, and 30-day risk of death was 3.4%. Per hour prolonged length of stay in the emergency department, the overall change in risk of death was close to zero, with a narrow 95% confidence interval of -0.5 to 0.7 percentage points. Prolonged emergency department stay was associated with a higher probability of being discharged from the emergency department without admission to the hospital. We found no substantial differences in length of hospitalisation for patients who were admitted. CONCLUSION: In this study, prolonged emergency department stay was not associated with increased risk of death.

Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department.

BACKGROUND: We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS). METHODS: The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients' electronic records (EPR) and mortality data from the Norwegian population registry. RESULTS: Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert. DISCUSSION: In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival. CONCLUSION: In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria.

Assessment of pain in a Norwegian Emergency Department.

BACKGROUND: Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital. MATERIALS AND METHODS: Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients' perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10. RESULTS: Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief. DISCUSSION: Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.

The acute sick and injured patients: an overview of the emergency department patient population at a Norwegian University Hospital Emergency Department.

OBJECTIVES: There is a lack of knowledge of the emergency department (ED) population in Norway; hence, the aim of this study was to describe the ED patient population at a Norwegian University Hospital. MATERIALS AND METHODS: Prospective data of all ED patients admitted to the main ED over a period of 2 months were collected. The patients' presenting complaint was registered using the International Classification of Primary Care-2 (ICPC-2). RESULTS: A total of 3163 patients arrived in the ED during the study period. The majority (71%) of patients presented with a complaint that was defined as a symptom in ICPC-2. The most common symptoms were abdominal pain (13%), chest pain (13%), and dyspnea (9%). The complaints of the remaining patients (29%) were primarily traumas, infections, and other diagnoses. CONCLUSION: ED patients have a diverse spectrum of presenting complaints and the majority of patients present with symptoms rather than a defined medical diagnosis.