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Resuscitation Plus Jun 2024Limited data exists regarding cardiovascular diseases (CVDs) and related emergencies such as out-of-hospital cardiac arrest (OHCA) in low- and middle-income countries... (Review)
Review
INTRODUCTION
Limited data exists regarding cardiovascular diseases (CVDs) and related emergencies such as out-of-hospital cardiac arrest (OHCA) in low- and middle-income countries (LMICs). The recent burden of disease report indicates a rising prevalence of CVDs in these settings like the Democratic Republic of Congo (DRC), likely associated with acute complications. Achieving improved outcomes necessitates resilient healthcare systems, including adequate emergency care and resuscitation systems. This study aims to characterize the current state of resuscitation systems in the DRC, contributing to the discourse on the burden of CVDs in LMICs and advocating for context-appropriate interventions to develop and reinforce these systems.
METHODS
A narrative review utilizing the modified survival framework of the Global Resuscitation Alliance was conducted. It encompassed the country's CVD epidemiological data, healthcare components, and emergency care system.
RESULTS
Analysis of limited available data revealed an underdeveloped and inadequately resourced healthcare system in the country, particularly its early-stage emergency care component. While specific data on out-of-hospital cardiac arrests were lacking, crucial components of the survival chain necessary for improved post-arrest outcomes were found to be largely deficient. Community-based first aid knowledge and practice were inadequate, the availability of automated external defibrillators (AEDs) and integrated ambulance services were either absent or insufficiently developed, and facility-based resuscitation capacity was predominantly in its infancy. Nonetheless, optimism is warranted due to recent government decisions to increase total health expenditure and progressively implement Universal Health Coverage.
CONCLUSION
Resuscitation systems in the DRC are largely non-existent, reflecting the country's underdeveloped healthcare system, particularly in emergency care. Urgent action is needed to develop and reinforce context-appropriate resuscitation systems to address the growing burden of CVD-related emergencies in LMICs.
PubMed: 38764760
DOI: 10.1016/j.resplu.2024.100656 -
BMC Medical Ethics May 2024Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress...
BACKGROUND
Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine.
METHODS
We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach.
RESULTS
We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope.
CONCLUSION
Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
Topics: Humans; Trust; Focus Groups; Emergency Medical Services; Emergency Medical Technicians; Female; Male; Adult; Attitude of Health Personnel; Decision Making; Morals; Middle Aged; Allied Health Personnel; Burnout, Professional
PubMed: 38762457
DOI: 10.1186/s12910-024-01061-9 -
Acute Medicine & Surgery 2024To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan.
AIM
To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan.
METHODS
A retrospective population-based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10-year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1-2). Sites at which OHCA occurred were classified into "sloped places (SPs)" (not easily accessible by emergency medical services [EMS] personnel due to slopes) and "accessible places (APs)" (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed.
RESULTS
No significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1-2: age group, witness status, first documented rhythm, bystander-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m-CPR) device or esophageal obturator airway (EOA), and year. Both m-CPR and EOA use were associated with a poor prognosis.
CONCLUSION
In a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander-initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.
PubMed: 38756720
DOI: 10.1002/ams2.966 -
Frontiers in Neurology 2024As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition,...
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
PubMed: 38756217
DOI: 10.3389/fneur.2024.1389056 -
BMJ Open May 2024The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families,...
OBJECTIVE
The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families, carers and healthcare professionals.
DESIGN/SETTING
An international research priority-setting partnership.
PARTICIPANTS
People who have experienced major trauma, their carers and relatives, and healthcare professionals involved in treating patients after major trauma. The scope included chest, abdominal and pelvic injuries as well as major bleeding, multiple injuries and those that threaten life or limb.
METHODS
A multiphase priority-setting exercise was conducted in partnership with the James Lind Alliance over 24 months (November 2021-October 2023). An international survey asked respondents to submit their research uncertainties which were then combined into several indicative questions. The existing evidence was searched to ensure that the questions had not already been sufficiently answered. A second international survey asked respondents to prioritise the research questions. A final shortlist of 19 questions was taken to a stakeholder workshop, where consensus was reached on the top 10 priorities.
RESULTS
A total of 1572 uncertainties, submitted by 417 respondents (including 132 patients and carers), were received during the initial survey. These were refined into 53 unique indicative questions, of which all 53 were judged to be true uncertainties after reviewing the existing evidence. 373 people (including 115 patients and carers) responded to the interim prioritisation survey and 19 questions were taken to a final consensus workshop between patients, carers and healthcare professionals. At the final workshop, a consensus was reached for the ranking of the top 10 questions.
CONCLUSIONS
The top 10 research priorities for major trauma include patient-centred questions regarding pain relief and prehospital management, multidisciplinary working, novel technologies, rehabilitation and holistic support. These shared priorities will now be used to guide funders and teams wishing to research major trauma around the globe.
Topics: Humans; Health Priorities; Surveys and Questionnaires; Research; Multiple Trauma; Wounds and Injuries; Caregivers; Health Personnel; Female; Male
PubMed: 38754886
DOI: 10.1136/bmjopen-2023-083450 -
PloS One 2024Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced...
Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.
Topics: Humans; Ambulances; United Kingdom; Restraint, Physical; Emergency Medical Services; Qualitative Research; Decision Making; Male; Allied Health Personnel; Female; Emergency Medical Technicians; Adult; Paramedics
PubMed: 38753728
DOI: 10.1371/journal.pone.0302524 -
Annals of Indian Academy of Neurology 2024Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously...
BACKGROUND
Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously conducted the first regional study to assess the factors delaying acute stroke care in India. The present study aims to understand and describe in depth the variables associated with prehospital delay among patients admitted with an acute ischemic stroke.
METHODS
Data were prospectively collected by conducting an in-depth interview of 470 acute ischemic stroke patients and their bystanders, aged above 18 years, presenting to the Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur. Patients who arrived within 4.5 h of symptom onset were considered as "early arrival" and those who arrived after 4.5 h were considered as "delayed arrival." Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation.
RESULTS
Of the 470 patients who met the inclusion criteria, 73 patients reached within 4.5 h (15.5%), whereas 397 patients arrived after 4.5 h. The mean age of acute stroke patients who reached within 4.5 h was 63 ± 13.7 years, whereas the mean age of those who reached after 4.5 h was 63 ± 12.1 years. Binary logistic regression performed to quantify the associations of prehospital factors showed an increased risk of prehospital delay among individuals with lack of awareness (odds ratio [OR] = 5.16 [3.040-8.757], < 0.001), followed by those for whom a vehicle was not available at the site of event (OR = 3.745 [1.864-7.522], < 0.001). Within the predefined socioeconomic strata, compared to lower class, upper middle class had less risk (OR = 0.135 [0.018-1.035], = 0.054), whereas the distance from first medical contact to emergency department contributed moderate risk (OR = 1.071 [1.028-1.116], < 0.001) for prehospital delay.
CONCLUSIONS
Health promotion techniques that increase public knowledge about the early signs of stroke, transferring patients directly to hospitals with thrombolysis capabilities, and making ambulance services more widely available are appropriate measures to reduce prehospital delay.
PubMed: 38751933
DOI: 10.4103/aian.aian_1091_23 -
European Heart Journal. Case Reports May 2024The use of mechanical circulatory support (MCS) has markedly increased over the last decade, so have the inter-hospital transfers, with the aim of being able to offer...
BACKGROUND
The use of mechanical circulatory support (MCS) has markedly increased over the last decade, so have the inter-hospital transfers, with the aim of being able to offer advanced heart failure (AHF) therapies and centralizing patients to tertiary centres.
CASE SUMMARY
In this article, we present the first in Europe long-distance air transfer of a patient supported by veno-arterial extracorporeal membrane oxygenator and Impella (ECPELLA), as a bridge to successful heart transplant. In our case report, a foreign young patient with AHF due to familiar cardiomyopathy required multiple MCS devices to achieve cardiovascular stability. After appropriate planning and multidisciplinary discussion, the patient was transferred on MCS to his country of origin via a fixed-wing airplane, in order to be assessed for heart transplantation. During take-off, the Impella flows temporarily dropped and a suction alarm was displayed; however, this rectified without intervention, and the rest of the flight was uneventful. One month after transfer, the patient underwent successful heart transplantation and remained clinically stable during the 12-month follow-up.
DISCUSSION
Our experience links together the current challenges in the evolving AHF strategies and the increased need for inter-facility cooperation. Both these clinical and logistic challenges appear to lead to possible improved outcomes, after appropriate assessment, training, and accurate planning. Our experience provides useful information on feasibility of long-distance transport of patients supported by ECPELLA in Europe.
PubMed: 38751900
DOI: 10.1093/ehjcr/ytae151 -
European Stroke Journal May 2024The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three...
INTRODUCTION
The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three different methods of simulated, rural prehospital computed tomography (CT) affected the time to prehospital treatment decision in acute stroke.
MATERIALS AND METHODS
In this pragmatic, simulation, pilot study of prehospital CT we investigated a conventional ambulance with transport to a standard care rural stationary CT machine managed by paramedics, a Mobile Stroke Unit (MSU), and a helicopter with a simulated CT machine. Each modality completed 20 real-life dispatches combined with simulation of predetermined animated patient cases with acute stroke symptoms and CT images. The primary endpoint of the study was the time from alarm to treatment decision.
RESULTS
Median time from alarm to the treatment decision differed significantly between the three groups ( = 0.0005), with 38 min for rural CT, 33 min for the MSU, and 30 min for the helicopter. There was no difference in time when comparing rural CT with MSU, nor when comparing the MSU with the helicopter. There was a difference in time to treatment decision between the rural CT and the helicopter ( < 0.0001). The helicopter had significantly lower estimated time from treatment decision to hospital ( = 0.001).
DISSCUSSION/CONCLUSION
Prehospital CT can be organized in several ways depending on geography, resources and need. Further research on paramedic run rural CT, MSU in rural areas, and helicopter CT is needed to find the optimal strategy.
PubMed: 38751332
DOI: 10.1177/23969873241252564 -
Tidsskrift For Den Norske Laegeforening... May 2024
PubMed: 38747659
DOI: 10.4045/tidsskr.24.0125