[The future of preclinical emergency medicine in Germany]

[When emergency physician and tele-emergency physician save life together : A case description on the application of prehospital telemedicine for ventricular tachycardia with hemodynamic instability]

Telemedicine has already entered the rescue service in some regions of Germany. This case description is about a telemedical emergency physician case where an emergency doctor was also at the scene of the emergency. The patient had a life-threatening ventricular tachycardia and became hemodynamically unstable. The emergency physician was still inexperienced and overwhelmed by the complex situation. She decided to contact the tele-emergency medical services (tele-ems) and could then be instructed to perform intraosseous access, drug treatment and electrical cardioversion in the unstable patient. The cooperation with the tele-ems physician enabled the still inexperienced emergency physician to perform a guideline-compliant treatment and to transport the stabilized patient to the hospital in a timely manner.

[System and skill utilization in an Austrian emergency physician system: retrospective study]

BACKGROUND

The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system.

METHODS

A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated.

RESULTS

A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively.

CONCLUSIONS

No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.

[Future of emergency medicine in Germany 2.0]

In 2003 an article on the future of prehospital emergency medicine in Germany was published in the journal Der Anaesthesist. Emergency medicine in Germany, which at that time was almost exclusively defined as prehospital emergency rescue, has evolved and now in-hospital domains have increasingly moved into the focus. At that time, the primary goal was to connect prehospital management with a smooth transition to hospital admission and further care in the hospital and to further optimize the rescue chain from the actual emergency through to causative treatment. Now after 15 years, the authors have critically assessed the development postulated in 2003 and reevaluated it. Which aspects could be developed further and become firmly established, what is still open and which questions in preclinical and clinical emergency treatment of the population will occupy us in the coming 15 years? With a critical eye to the past, the present contribution aims to capture the essential and new topics and open questions and provide a fresh perspective for the future of emergency medicine. Regulation at the state level or even lower levels of government often stand in contrast to more sweeping and economically effective approaches at the federal level. Prehospital emergency medicine in Germany is on the whole well-positioned with respect to facilities and personnel; however, as far as the economic situation and the utilization of available systems are concerned, there is still substantial room for improvement.

[Practical training for paramedics : Transformation at the Leipzig University teaching hospital]

BACKGROUND

The "Notfallsanitätergesetz" (the law pertaining to paramedics), which came into effect in January 2014, has fundamentally changed the training of health personnel in German prehospital emergency medicine. The apprenticeship now takes 3 years including 720 h of practical training in eligible hospitals. To date, however, there has been little experience of how the contents of the guidelines for practical training ("Ausbildungs- und Prüfungsverordnung") can be reasonably applied in the teaching hospitals.

METHODS

In a total of nine interdisciplinary working group meetings between October 2014 and June 2016, we developed a curriculum concerning the practical training of paramedics to implement the contents of the guidelines for practical training in a didactically and an organizationally meaningful way.

RESULTS

The implementation of the practical training of paramedics is an excellent chance for the teaching hospitals to contribute to higher quality prehospital emergency medicine. Otherwise, the teaching hospitals face an organizational and personal effort that is not to be underestimated. Thus, a modular curriculum constitutes the possibility of standardizing practical training and simultaneously reducing the time and expenditure for the participating hospitals.

CONCLUSION

The development of a unique curriculum for the practical training of paramedics may contribute to standardized, high-quality, and cost-efficient training.

[Air rescue: current significance and practical issues]

Germany has a nationwide and powerful helicopter emergency medical services system (HEMS), which executes primary rescue missions and interhospital transfer of intensive care patients. In recent years the range of HEMS missions has become modified due to demographic changes and structural changes in the healthcare system. Furthermore, the number of HEMS missions is steadily increasing. If reasonably used air rescue contributes to desired reductions in overall preclinical time. Moreover, it facilitates prompt transport of patients to a hospital suitable for definitive medical care and treatment can be initiated earlier which is a particular advantage for severely injured and critically ill patients. Because of complex challenges during air rescue missions the qualifications of the HEMS personnel have to be considerably higher in comparison with ground based emergency medical services.

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

BACKGROUND

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible. In preparation for bringing such a system into practice within the research project "Med-on-@ix", a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

MATERIAL AND METHODS

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

RESULTS

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p=0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p=0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p=0.0421); synchronized shock (6/14 vs. 14/15; p=0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p=0.0092); mean time to inform trauma centre 547 vs. 189 s (p=0.0001). No significant impairment of performance was detected in TMA groups.

CONCLUSIONS

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

[E-health in emergency medicine - the research project Med-on-@ix]

There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.

[Time in care of trauma patients in the air rescue service: implications for disposition?]

BACKGROUND

Time plays a crucial role in treating multiple traumatized patients and delays in management worsen the prognosis. Furthermore, current studies show that trauma patients profit from primary delivery to a trauma center. Therefore, the goal of physician-staffed ground and air rescue services in Germany is to treat these patients as quickly as possible and deliver them to a suitable trauma center. The aim of the present study was to investigate prehospital treatment times for the air rescue team in terms of disposition and efficiency when a ground rescue team was already present at the scene.

METHODS

In a nationwide, multicenter analysis emergency missions carried out for traumatological emergencies in 2006 by 28 air rescue centers (ARC) of the TeamDRF and 6 ARC of the federal police were evaluated using the medical database MEDAT of the German Air Rescue Service. A distinction was made between combined missions with (MEDAT 1 group) and without (MEDAT 2 group) physician-staffed ground emergency medical services already being present at the emergency site and in particular the rescue helicopter treatment times for both groups were investigated. Furthermore, combined missions (MAN 1 group) and solo missions (MAN 2 group) for traumatological emergencies in the period 01.05.2006 to 31.01.2007 were investigated in a complementary prospective regional study at the ARC Heidelberg/Mannheim "Christoph 53". In both groups the total treatment times for all physician-staffed emergency systems involved in treatment at the scene were investigated.

RESULTS

Nationwide, 26,010 primary missions could be evaluated and of these, 11,464 missions were traumatological emergencies (44.1%) with 2,229 (19.4%) carried out by the MEDAT 1 group and 9,235 (80.6%) by the MEDAT 2 group. For both groups the helicopter treatment times depended on the severity of the injuries (NACA classification) and were between 17+/-12 min (NACA I) and 34+/-19 min (NACA VII) in MEDAT group 1 versus 21+/-10 and 36+/-19 min in MEDAT group 2 (p<0.05, p<0.001), respectively. In the MEDAT 1 group, the average treatment times were between 2.8 min (NACA VII) and 8.1 min (NACA VI) shorter compared with the MEDAT 2 group. Moreover, when taking the severity of the injury into consideration, a regular and significantly higher treatment effort (e.g. intubation, repositioning and chest tube insertion) and a greater proportion of patients who were transported to the clinic via rescue helicopter were observed for the MEDAT 1 group than for the MEDAT 2 group. In the regional study 670 primary missions were evaluated including 382 traumatological emergencies (57%). From these, 90 multiple trauma patients (NACA V) were not resuscitated or died at the scene, 58 from the MAN 1 group and 32 from the MAN 2 group, and were investigated more closely. The helicopter treatment times were comparable to those observed in the nationwide study and were found to be 26+/-12 min and 35+/-20 min (p<0.05), respectively. In the MAN 1 group the treatment times for the ground rescue services up to the time when the helicopter arrived was 22+/-11 min on average; the total treatment time was 48+/-15 min and 12+/-8 min longer than the time for the MAN 2 group, which was statistically significant. In the MAN 1 group the helicopter was alerted on average 17+/-15 min after the physician-staffed ground rescue services arrived at the emergency site. Treatment by the rescue helicopter teams was significantly more extensive in the MAN 1 group.

CONCLUSIONS

The treatment times for the helicopter were several minutes shorter when a physician-staffed ground rescue team had already arrived at the emergency site. However, it must be assumed that the total prehospital time is significantly longer for such missions. These results directly affect the disposition at the emergency dispatch center and indicate that when air rescue is required to transport a patient to hospital, the helicopter should be alerted at an early stage. In such settings, it is likely that initiating the operation in this way would improve the prognosis of severely injured patients and save costs.

[Intraosseous puncture in preclinical emergency medicine. Ten years experience in air rescue service]

INTRODUCTION

The intraosseous puncture (IO) is a fast and safe alternative to the puncture of peripheral veins in emergency situations in children < or =6 years of age. The purpose of this paper is to summarize 10 years of experience on the prehospital use of the IO method by the Helicopter Emergency Medical Service (HEMS) "Christoph 22", Ulm.

MATERIALS AND METHODS

This was a retrospective study from 1 January 1996 to 31 December 2005.

RESULTS

Out of a total of 9,549 missions, the proportion of children was 11.1%. In 27 children (4.2% of the children < or =6 years of age) an IO puncture was performed. Patients of the IO group were younger (1.0 vs. 3.7 years of age; p<0.001) and showed a higher degree of injury severity (NACA 6 vs. 4; p<0.001) compared to the total children group. In all children of the IO group (100%), the intraosseous puncture was the method of first choice to obtain access to the vascular system by the HEMS team. In 96.4% of these cases (26/27), the first IO puncture attempt was successful - in one child, a second puncture attempt was necessary. A standardized puncture technique was performed using the proximal tibia. The time required for successful placement of the IO infusion line was 60 s or less in all cases. In 37% of the cases (10/27) the IO infusion line was used for induction of general anaesthesia; dosage and onset of administered drugs were described as being equivalent to a peripheral infusion line. In all cases, the IO needle was replaced in-hospital within 2 h by a central or peripheral iv line. No complications were observed.

CONCLUSIONS

The IO infusion technique is a simple, fast and safe alternative method for emergency access to the vascular system in children < or =6 years of age in the prehospital setting.

[Spectrum of patients in prehospital emergency services. What has changed over the last 20 years?]

BACKGROUND

In Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes.

METHODS

In a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients' demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions performed by prehospital emergency physician.

RESULTS

In 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV-VI (39% vs. 50%) or patients with GCS < or =8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each category was higher than in 1984 (NACA IV-VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01).

CONCLUSIONS

The results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

Realistic assessment of the physican-staffed emergency services in Germany

In Germany the emergency medical services, which include dispatching emergency physicians to the scene, are considered to be among the best in the world. However, the hospitals admitting these patients still report shortcomings in prehospital care. The quality of an emergency medical service depends on both formal qualification and experience in managing such emergencies. Therefore, we determined how frequently emergency medical service physicians in Germany actually encountered complex and demanding emergency situations outside the hospital and how often they had to carry out emergency interventions. We therefore evaluated data from more than 82,000 ground emergency medical service scene calls registered in the MIND ("minimaler Notarztdatensatz") data base of the state of Baden-Wuerttemberg, Germany and more than 47,000 helicopter emergency medical service scene calls from the "Luftrettungs-, Informations- und Kommunikationssystem" (LIKS) data base of the German ADAC air rescue service. The results, which were unexpectedly distinct, impressively demonstrate that in part emergency medical service staff only encountered some emergencies very rarely. In particular, patients with life-threatening conditions such as acute coronary syndrome, stroke, head trauma, as well as multiple trauma were only treated once every 0.4-14.5 months and cardiopulmonary resuscitation and intubation were only carried out once every 0.5-1.5 months. Furthermore, a time period of 6 months to more than 6 years may pass before a chest tube has to be placed. There are, of course, considerable differences between ground and helicopter emergency medical services. Particularly in areas where the frequency of such emergency cases is low, the clinical experience required to competently manage a demanding emergency situation cannot be gained or maintained just by working in the emergency medical system. As a result of the general pressure to cut costs and also of changes in hospital politics, however, only highly qualified and experienced emergency medical services may survive in Germany in the long term. In addition to formal qualifications and accompanying practice-related courses, future emergency medical service personnel should be drafted from clinical department staff that are experienced in treating severely ill and severely injured patients.

[Preclinical management of multiple trauma]

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Invasive Techniken in der Notfallmedizin

Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.