Emerg. Care Med., Volume 1, Issue 3 (September 2024) – 12 articles

Inter-hospital transfers remain a significant part of emergency care service missions, even though efforts have been made to change this. We examined the use of prehospital emergency care units in inter-hospital patient transfers in one wellbeing services county in Finland. We evaluated the potential strain they place on regional prehospital emergency care readiness, and examined how these transfers arise between different regions, populations, and healthcare centers. This was a register-based pilot study using prehospital emergency care inter-hospital transfer mission statistics within the wellbeing services county of Pirkanmaa, Finland during 2020 and 2021. The data were extracted from the emergency care service’s field management program. A descriptive analysis of the data was performed, in which interdependencies between several variables were examined. During the two years, there were 5812 prehospital emergency care inter-hospital transfer missions dispatched to prehospital emergency care units. The number of prehospital emergency care inter-hospital transfer missions was especially notable in rural regions, where there were also fewer units available. Based on the results, the criteria for prehospital emergency care use in inter-hospital transfers require clarification, since there is an observable strain caused by these transfers on regional emergency care readiness. The results of this pilot study encourage further studies on the use of prehospital emergency care units in inter-hospital patient transfers. Full article

Background: Neonatal hypoxic respiratory failure (HRF) secondary to PPHN (persistent pulmonary hypertension of the newborn) is an uncommon but life-threatening complication. Despite advances in therapeutic interventions, there are neonates who may require ECMO (extracorporeal membrane oxygenation), which improves survival. In establishing the capability of ECMO in transport in New South Wales, significant variation in referral thresholds and management of PPHN in referring hospitals has been noted. Aim: To review cases referred to the Newborn and paediatric Emergency Transport Service (NETS) for consideration of ECMO due to HRF in neonates. The aetiology of HRF, the number of retrievals and their short-term outcomes were reported. Methods: A retrospective audit of referrals to NETS (January 2019 to December 2022) of infants aged <28 days with HRF for ECMO. Patient demographics, management, advice at the time of call and the outcome are described. Results: The mean weight was 3511 g, mean gestation was 37.1 weeks and 69% of the patients were male. The main diagnoses were MAS/PPHN (50%), and there was variation in inotropes and ventilation strategies at the time of the referral. Six (25%) of the fifteen babies who were transported by NETS to paediatric intensive care were placed on ECMO at the referring hospital. A further six babies were stabilised at the referral centre following NETS co-ordinated specialist advice and did not require retrieval or ECMO. All the babies who received ECMO and survived had normal early development (<6 months) with normal head US or MRI imaging. Conclusions: Optimising ventilation and inotrope management can eliminate the need for ECMO prior to or following retrieval. Early referral for the consideration of ECMO and a collaborative discussion can assist in optimising conventional therapy, thus eliminating the need for ECMO. Neonates requiring ECMO for HRF have good survival rates with good short-term neurological outcomes. Full article

Methaemoglobinaemia (MetHb) is a functional anaemia that can be life-threatening in severe cases. MetHb in adults and older children usually results from exposure to toxins from ingestion or skin exposure, whereas MetHb in infants under six months old usually occurs due to exposure to well water, severe metabolic acidosis from diarrhoea, or, in rare cases, secondary to cow’s milk protein allergy (CMPA). In this case report, a young infant presented acutely with shock secondary to profuse diarrhoea and MetHb requiring intravenous fluids and methylene blue and was subsequently diagnosed with CMPA. The early recognition and prompt treatment of CMPA may prevent the recurrence of MetHb symptoms and excessive diagnostic testing in this vulnerable population. Full article

Prehospital electrocardiogram (PH-ECG) transmission is an important technology for reducing door-to-balloon time, but the decision to transmit often depends on the discretion of emergency medical technicians (EMTs). Additionally, studies based on real-world data remain insufficient. This study reports a machine learning-based method for classifying the severity of PH-ECG images and explores its feasibility. PH-ECG data were compiled from 120 patients between September 2017 and September 2020. The model we created from these data was the first classification model for PH-ECG images using data from a Japanese study population and showed a weighted F1-score of 0.85 and an Area Under the Curve (AUC) of 0.93. This result can be interpreted as having an excellent balance of sensitivity and specificity. The Cohen’s Kappa coefficient between AI’s inferences and the correct labels created by two cardiologists was 0.68 (p < 0.05), which is considered “substantial” according to the guidelines presented by Landis and Koch. In this study, although we were not able to remove noise caused by patient movement or electrode detachment, the results indicate that image-based abnormality detection from PH-ECGs is feasible and effective, particularly in regions like Japan where ECG data are often stored and transmitted as images. In addition, in our region, paramedics follow a multi-step process to decide whether to transmit an ECG, which takes time for the first screening. However, if the ECG is transmitted when either the paramedics or the deep learning model detects an abnormality, it is expected to reduce reading time and door-to-balloon time, as well as decrease false negatives. Full article

Insulin analogs are basic drugs that are widely used in the treatment of diabetes around the world. Suicides with their use are described as rare, occurring mainly in the population of diabetic patients due to their easy access to the drug and knowledge of its properties. Among non-diabetic people, insulin is used for suicidal purposes mainly by adults with medical education. A case of a 15-year-old girl found unconscious by her mother at night was described. The patient was immediately transported to the hospital, where she was diagnosed with her first severe hypoglycemic episode of unknown origin. Once conscious and in a better state, the patient admitted to having taken insulin, which she had stolen from her diabetic mother, for suicidal purposes. The patient had no history of mental illness or self-destructive behavior. The patient was referred to psychiatric care. Suicides and suicide attempts involving insulin are usually observed among people with chronic diabetes. Moreover, such attempts are made by adults who know the mechanism of action of the drug. In the pediatric group without diabetes, such cases are extremely rare. Additionally, the issue of similar behaviors becomes very important due to the increasing popularity and availability of insulin therapy and the possibilities of obtaining information about using it to commit suicide from the Internet. Particular vigilance is required in pediatric emergency departments when a patient is identified as having a first episode of severe hypoglycemia of unknown origin. Full article

Background: Nurses in intra-hospital emergency teams are required to be competent in responding to situations of clinical deterioration and emergency. This study aimed to map the extent, variety, and nature of the literature on the competences of the intra-hospital emergency teams nurse. Methods: A scoping review based on the principles of the Joanna Briggs Institute. The search of the databases was conducted in July and August 2023, and the search strategy was adjusted. The analysis of the relevance of the articles, data extraction, and synthesis were conducted by two reviewers. Discrepancies were resolved by a third reviewer. The data were extracted using the competency outcomes and performance assessment (COPA) model. Results: Fourteen results were analyzed, and the competences organized by the domains of the COPA model which are considered by some authors to be advanced or specialized are as follows: assessment and intervention, communication, critical thinking, teaching, human caring relationships, management, leadership, and knowledge integration. Other competences, such as self-confidence, ability to remain calm, concentration, quick reaction, and a sense of humor, were mentioned. Conclusions: The results highlighted the competences of the intra-hospital emergency team nurse. This knowledge could contribute to educational programs and shape the competency profile of intra-hospital emergency team nurses. Full article

Emergency medicine (EM) demands continuous adaptation and refinement of training methodologies to equip healthcare professionals with the expertise to effectively manage complex and time-sensitive patient presentations. Artificial intelligence (AI), with its remarkable ability to process vast amounts of data, identify patterns, and make predictions, holds immense promise for enhancing the advanced training and education of EM physicians. This narrative review aims to discuss the potential of AI in transforming EM training and highlight the specific applications of AI in personalized learning, realistic simulations, data-driven decision support, and adaptive assessment, along with further exploring the benefits and challenges of AI-powered EM training. A comprehensive literature search was conducted using PubMed, MEDLINE, and Google Scholar to identify relevant studies focusing on AI applications in EM and EM training. The search terms included “artificial intelligence”, “emergency medicine”, “training”, “education”, “personalized learning”, “simulations”, “decision support”, and “assessment. Articles published in the past ten years were prioritized to ensure the inclusion of current advancements in the field. AI offers a plethora of opportunities to revolutionize EM training, including the following: Personalized learning: AI-powered systems can tailor educational content and pace to individual trainees’ needs, ensuring optimal instruction and knowledge acquisition. Realistic simulations: AI-powered simulations provide immersive experiences for trainees to practice clinical decision making under simulated pressure. Data-driven decision support: AI-powered systems analyze vast amounts of data to provide trainees with real-time recommendations and insights for informed clinical decisions. Adaptive assessment: AI-powered tools assess trainee progress dynamically, providing personalized feedback and identifying areas for improvement. Conclusions: AI integration into EM training holds immense promise for enhancing trainee learning and improving patient outcomes. By embracing AI, we can cultivate a new generation of EM physicians equipped to meet the ever-changing demands of this critical medical specialty. Full article

Healthcare workers were substantially impacted by the COVID-19 pandemic. Front-line workers continue to suffer higher rates of distress and burnout than they had before the pandemic. In order to heal the front-line workforce and plan for the next disaster in healthcare, it is necessary to carefully reflect on the COVID-19 pandemic and integrate that experience with the existing literature on disaster mental health. In this narrative review, the disaster MH framework for community disasters is adapted to the healthcare setting. The first principle of disaster mental health is to distinguish between normative distress and psychopathology. The second step in the framework includes stabilization, triage, and referral to psychiatry. The third step in disaster mental health framework is intervention for psychological distress and psychiatric illness. Interventions for emotional distress may include psychological first aid (PFA), psychological debriefing, crisis counseling, and psychoeducation, whereas interventions for psychopathology include pharmacotherapy and/or psychotherapy. Unfortunately, many front-line HCWs were indeed damaged by the pandemic and continue to report high levels of burnout and distress, in part because the MH response to the pandemic was lacking or otherwise inadequate. Screening, triage and referral to MH resources, and interventions are fundamental aspects of an MH response to disaster and may be coordinated with formal operational procedures within incident command structures. Setting up these structures in advance, preferentially, and establishing networks of psychiatrists and crisis MH responders who will implement them are essential. By reflecting on the pandemic and learning from prior disasters, we can care for those who care for our sickest patients. Full article

Bell’s Palsy poses a significant challenge in emergency care settings due to its sudden onset and potential long-term consequences. This review paper explores the current evidence and perspectives on the use of acupuncture as a complementary approach in the emergency management of Bell’s Palsy. A comprehensive search of electronic databases was conducted to identify relevant studies regarding acupuncture in Bell’s Palsy management. The key findings and viewpoints were synthesized to provide an overview of the efficacy, safety, and clinical considerations associated with acupuncture in emergency care settings. This review highlights a growing body of evidence supporting the use of acupuncture as an adjunctive therapy for Bell’s Palsy. Studies suggest that acupuncture may help alleviate symptoms, promote nerve regeneration, and improve functional outcomes when combined with standard medical treatments. Furthermore, acupuncture is generally well tolerated and devoid of serious adverse effects, making it a potentially valuable intervention in emergency settings. While further research is needed to elucidate the mechanisms underlying the therapeutic effects of acupuncture in Bell’s Palsy, current evidence suggests that it holds promise as a non-invasive and cost-effective adjunctive therapy in emergency care. Clinicians should consider integrating acupuncture into comprehensive treatment protocols for Bell’s Palsy, taking into account patient preferences, clinical expertise, and available resources. Full article

Background: Safe inter-hospital transport of critically ill patients is a complex procedure where nurses are integral to maintaining patient safety. A structured checklist is pivotal to ensuring the transfer process mitigates potential complications. Objective: The objective of this scoping review was to devise and implement a detailed checklist to enhance patient safety during the transfer of critically ill patients. Methods: A comprehensive literature review was conducted by Joanna Briggs Institute’s guidelines across several databases including MEDLINE, CINAHL Complete, LILACS, and Scopus. The search considered works published in Portuguese, English, or Spanish from 2008 onwards. A total of eight studies met our inclusion criteria and were selected for detailed analysis. Results: Our analysis delineated the critical clinical information necessary to compose an effective transfer checklist. This checklist was developed through iterative refinement, informed by the literature and appraised during a focus group meeting with experts. Subsequent to its development, the checklist was implemented in the emergency department of a Central Portuguese hospital. Conclusions: This scoping review emphasizes the significance of evidence-based protocols and clear communication in safeguarding patient welfare during critical transfers. The developed checklist is a tool that standardizes care processes, supports clinical decision-making, and is instrumental in minimizing adverse events during inter-hospital transfers. Full article

The most effective strategy to save the life of a victim of out-of-hospital cardiac arrest (OHCA) is to provide aid as early as possible. To achieve this objective, widespread dissemination of knowledge on basic life support and defibrillation (BLSD) in the general population is necessary. In recent years, evidence has been emerging supporting the effectiveness of public-access defibrillation (PAD) programs; the diffusion of automatic external defibrillators (AEDs) and the knowledge of their correct use among lay rescuers are associated with a higher survival rate and better neurological outcomes among OHCA victims. This study aims to implement and monitor a BLSD training program involving an entire city in Italy. Since 2016, a PAD program has been implemented in Busca (CN), a small town in the northwest of Italy. The project was divided into three phases: (1) the diffusion of AEDs in the most-frequented places in the city; (2) BLSD training aimed at reaching the most significant possible number of citizens; (3) the training of all schoolchildren in the basics of first aid. The retention of the concepts learned was assessed via a multiple-choice questionnaire proposed months after the training events. From 2016 to 2023, 42 BLSD courses were held, which trained 1302 adults (12.8% of citizens) with a female/male ratio of 0.9 and a median age of 46 (range: 32–59 years). The participants in the courses were volunteers from associations (59%), athletes (16%), ordinary citizens (13%), school staff (10%), and municipal employees (2%). At the start of the project in 2016, the first 11 AEDs were positioned. To date, the municipal area can count on 25 always-available defibrillators to reach each area within 4 minutes. Furthermore, 1500 school pupils were trained. The retention of the learned notions was excellent. After training, 92% of adult participants and 90% of the schoolchildren reported being willing to provide help in the event of cardiac arrest. The project combined the widespread diffusion of AEDs with a significant number of citizens able to use them, effectively providing cardiopulmonary resuscitation. This project ensured that an entire community shared the goal of saving the lives of people affected by OHCA. Full article

Gastrointestinal bleeding is the main cause of admission to the emergency services of patients taking direct-acting oral anticoagulants (DOACs). Little is known about the effects of treatment modification on the risk of readmission, especially in elderly patients. This retrospective observational study included elderly patients with atrial fibrillation who were on DOACs and who were admitted to the emergency department due to gastrointestinal bleeding from 2018 to 2023. To evaluate the risk factors for readmission 90 days after discharge, a multivariate analysis was conducted, which included patient comorbidities, concomitant treatment, changes in anticoagulant treatment, and the prescription of DOACs at discharge. One hundred and thirty-nine patients were included. At discharge, anticoagulant therapy was modified in 44 (31.6%) patients, 16 (36.3%) patients were switched from one DOAC to another, 23 (52.2%) to heparins, and 5 (11.3%) to vitamin K antagonists. A total of 21 (15.1%) patients returned to the emergency department within 90 days after discharge due to new bleeding events. No significant differences were observed depending on the modification of treatment at discharge. The presence of cognitive impairment was the only factor associated with readmission at 90 days. Patients who undergo treatment with DOACs and have gastrointestinal bleeding at discharge are at risk of readmission to the emergency room due to new bleeding events. No benefit was observed in modifying anticoagulant treatment at discharge. Full article