Being cold when injured in a cold environment--patients' experiences

Effect of wet clothing removal on skin temperature in subjects exposed to cold and wrapped in a vapor barrier: a human, randomized, crossover field study

BACKGROUND

Prehospital care for cold-stressed and hypothermic patients focuses on effective insulation and rewarming. When encountering patients wearing wet clothing, rescuers can either remove the wet clothing before isolating the patient or isolate the patient using a vapor barrier. Wet clothing removal increases skin exposure but avoids the need to heat the wet clothing during rewarming. Leaving wet clothing on will avoid skin exposure but is likely to increase heat loss during rewarming. This study aimed to evaluate the effect of wet clothing removal compared to containing the moisture using a vapor barrier on skin temperature in a prehospital setting.

METHODS

This randomized crossover experimental field study was conducted in a snow cave in Hemsedal, Norway. After an initial cooling phase of 30 min while wearing wet clothes, the participants were subjected to one of two rewarming scenarios: (1) wet clothing removal and wrapping in a vapor barrier, insulating blankets, and windproof outer shell (dry group) or (2) wrapping in a vapor barrier, insulating blankets, and windproof outer shell (wet group). The mean skin temperature was the primary outcome whereas subjective scores for both thermal comfort and degree of shivering were secondary outcomes. Primary outcome data were analyzed using the analysis of covariance (ANCOVA).

RESULTS

After an initial decrease in temperature during the exposure phase, the dry group had a higher mean skin temperature compared to the wet group after only 2 min. The skin-rewarming rate was highest in the initial rewarming stages for both groups, but increased in the dry group as compared to the wet group in the first 10 min. Return to baseline temperature occurred significantly faster in the dry group (mean 12.5 min [dry] vs. 28.1 min [wet]). No intergroup differences in the subjective thermal comfort or shivering were observed.

CONCLUSION

Removal of wet clothing in combination with a vapor barrier increases skin rewarming rate compared to encasing the wet clothing in a vapor barrier, in mild cold and environments without wind.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT05996757, retrospectively registered 18/08/2023.

A phenomenological interview study with patients being non-conveyed in the ambulance service

BACKGROUND

Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients' non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context.

METHODS

A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region.

RESULTS

Patients' lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security.

CONCLUSIONS

Patients' lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation's complexity from a patient's perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.

Patients experience of warmth and coldness in connection with surgery - a phenomenological study

Purpose: The aim was to describe patients' lived experience of warmth and coldness in connection with surgery. Methods: A reflective lifeworld research (RLR) approach founded on phenomenology and the methodological principles of openness, flexibility, and bridling were used. The data consisted of 16 in-depth interviews with patients from four hospitals in Sweden. Results: Warmth and coldness in connection with surgery means an expectation to maintain one´s daily life temperature comfort. When patients' needs of temperature comfort is fulfilled it give a sense of well-being and calmness. Despite the body is covered there are feelings of vulnerability. When patients have the ability to change their own temperature comfort, they feel independent. Conclusion: The individual feeling of temperature comfort could be affected or changed to discomfort during the perioperative context, and an intervention is required to avoid suffering due to the care. An ability to independently influence one´s own temperature comfort can strengthen the patient, whereas the opposite entails suffering in silence. The phenomenon is also related to feelings of confidence about receiving the best care as well as being exposed and vulnerable. When the patient´s need of comfortable temperature is met then feelings of security and sense of well-being emerged.

Trauma Prehospital Hypothermia Prevention and Treatment: An Observational Study

BACKGROUND

Hypothermia in trauma patients causes increased morbidity and mortality. Swift recognition and treatment are important to prevent any further heat loss. In addition, patient discomfort from cold decreases satisfaction with care. The administration of active and passive rewarming measures is important in the prevention and treatment of hypothermia, but their use in prehospital trauma patients in Portugal has not been previously reported.

OBJECTIVE

To assess the prevalence of hypothermia, the impact of rewarming measures, and the management of the discomfort caused by cold.

METHODS

This is a prospective cohort study conducted in Immediate Life Support Ambulances in Portugal between March 1, 2019, and April 30, 2020.

RESULTS

This study included records of 586 trauma patients; of whom, 66.2% were men. Cranioencephalic trauma was the most common trauma observed, followed by lower limb and thoracic traumas. Mean body temperature increased 0.12 °C between the first and last assessments (p < .05). Most patients experiencing a level of discomfort of 5 or more on a 0-10 scale reported improvement (from 17.2% to 2.4% after nurses' intervention). Warmed intravenous fluids proved to be effective (p < .05) in increasing body temperature, and passive rewarming measures were effective in preventing hypothermia.

CONCLUSIONS

Hypothermia management has to consider the initial temperature, the season, the available rewarming measures, and the objectives to be achieved. The optimization of resources for the monitoring and treatment of hypothermia should be a priority in prehospital assistance. The implementation of rewarming measures improves patients' outcomes and decreases the discomfort caused by cold in prehospital care.

Patient experience studies in the circumpolar region: a scoping review

OBJECTIVES

Patient experiences with health systems constitute a crucial pillar of quality care. Across the Arctic, patients' interactions with the healthcare system are influenced by challenges of access, historical inequities and social determinants. This scoping review sought to describe the range and nature of peer-reviewed literature on patient experience studies conducted within the circumpolar region.

DESIGN

In a partnership between Danish/Greenlandic, Canadian and American research teams, a scoping review of published research exploring patient experiences in circumpolar regions was undertaken.

DATA SOURCES

Seven electronic databases were queried: MEDLINE, Embase, Scopus, 'Global Health 1910 to 2019 Week 11', CINAHL, PsycINFO and SveMed+.

ELIGIBILITY CRITERIA

Articles were eligible for inclusion if they (a) took place in the circumpolar region, (b) reported patients' perspective and (c) were focussed primarily on patient experiences with care, rather than satisfaction with treatment outcome.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening, full-text review and data extraction was conducted by four researchers. Bibliometric information such as publication date and country of origin was extracted, as was information regarding study design and whether or not the article contained results relevant to the themes of Indigenous values, rural and remote context, telehealth and climate change. Two researchers then synthesised and characterised results relevant to these themes.

RESULTS

Of the 2824 articles initially found through systematic searches in seven databases, 96 articles were included for data extraction. Findings from the review included unique features related to Indigenous values, rural and remote health, telehealth and climate change.

CONCLUSIONS

The review findings provide an overview of patient experiences measures used in circumpolar nations. These findings can be used to inform health system improvement based on patient needs in the circumpolar context, as well as in other regions that share common features. This work can be further contextualized through Indigenous methodologies such as sharing circles and community based participatory methods.

Cabin temperature during prehospital patient transport - a prospective observational study

Background

Few studies have investigated the patient compartment temperatures during ambulance missions or its relation to admission hypothermia. Still hypothermia is a known risk factor for increased mortality and morbidity in both trauma and disease. This has special relevance to our sub-arctic region’s pre-hospital services, and we prospectively studied the environmental temperature in the patient transport compartment in both ground and air ambulances.

Methods

We recorded cabin temperature during patient transport in two ground ambulances and one ambulance helicopter in the catchment area of the University Hospital of North Norway using automatic temperature loggers. The data were collected for one month in each of the four seasons. We calculated the sum of degrees Celsius below 18 min by minute to describe the patient exposure to unfavourably low cabin temperature, and present the data as box plots. The statistical differences between transport mode and season were analysed with ANCOVA.

Results

The recorded cabin temperatures were higher during the summer than the other three seasons. However, we also found that helicopter transports were performed at lower cabin temperatures and with significantly more exposure to unfavourably low temperatures than the ground ambulance transports. Furthermore, the helicopter cabin reached the final temperature much slower than the ground ambulance cabins did or remained at a lower than comfortable temperature.

Conclusions

Helicopter cabin temperature during ambulance missions should be monitored closer, particularly for patients at risk for developing admission hypothermia.

Caring science research in the ambulance services: an integrative systematic review

BACKGROUND

The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings.

AIM

This integrative systematic review aims to describe caring science research content and scope in the ambulance services.

DATA SOURCES

Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156.

REVIEW METHODS

The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five-stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3-level scale, and data relevance was evaluated on a 2-level scale.

RESULTS

After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision-making; Public environment and patient safety; Life-changing situations; and Ethics and values.

CONCLUSION

Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional-patient relation, with special focus on value conflicts in emergency situations.

Protection against cold - a survey of available equipment in Swedish pre-hospital services

BACKGROUND

The aim of this study was to survey the current equipment used for prevention, treatment and monitoring of accidental hypothermia in Swedish pre-hospital services.

METHODS

A questionnaire was sent to all road ambulance services (AS), the helicopter emergency medical services (HEMS), the national helicopter search and rescue service (SAR) and the municipal rescue services (RS) in Sweden to determine the availability of insulation, active warming, fluid heating, and low-reading thermometers.

RESULTS

The response rate was 77% (n = 255). All units carried woollen or polyester blankets for basic insulation. Specific windproof insulation materials were common in the HEMS, SAR and RS units but only present in about half of the AS units. Active warming equipment was present in all the SAR units, but only in about two-thirds of the HEMS units and about one-third of the AS units. About half of the RS units had the ability to provide a heated tent or container. Low-reading thermometers were present in less than half of the AS and HEMS units and were non-existent in the SAR units. Pre-warmed intravenous fluids were carried by almost all of the AS units and half of the HEMS units but infusion heaters were absent in most units.

CONCLUSION

Basic insulation capabilities are well established in the Swedish pre-hospital services. Specific wind and waterproof insulation materials, active warming devices, low-reading thermometers and IV fluid heating systems are less common. We suggest the development and implementation of national guidelines on accidental hypothermia that include basic recommendations on equipment requirements.

The opinions of ambulance personnel regarding using a heated mattress for patients being cared for in a cold climate - An intervention study in ambulance care

The purpose of the study was to describe the opinions of ambulance personnel regarding differences between using a heated mattress and a standard ambulance mattress. This study was an intervention study with pre- and post-evaluation. Evaluations of the opinions of personnel regarding the standard unheated mattress were conducted initially. After the intervention with new heated mattresses, follow-up evaluations were conducted. Ambulance personnel (n=64) from an ambulance station in northern Sweden took part in the study, which ran from October 2014 until February 2016. There were differences in opinions regarding the standard unheated mattress and the new heated mattress. The evaluation of the proxy ratings by the personnel showed that the heated mattress was warmer than the standard mattress, more pleasant to lie on and that patients were happier and more relaxed than when the standard mattress was used. The ambulance personnel in this study rated the experience of working with the heated mattress as very positive and proxy rated that it had a good effect on patient comfort. A heated mattress can be recommended for patients in ambulance care, even if more research is needed to receive sufficient evidence.

Effect evaluation of a heated ambulance mattress-prototype on thermal comfort and patients' temperatures in prehospital emergency care--an intervention study

Background

The ambulance milieu does not offer good thermal comfort to patients during the cold Swedish winters. Patients’ exposure to cold temperatures combined with a cold ambulance mattress seems to be the major factor leading to an overall sensation of discomfort. There is little research on the effect of active heat delivered from underneath in ambulance care. Therefore, the aim of this study was to evaluate the effect of an electrically heated ambulance mattress-prototype on thermal comfort and patients’ temperatures in the prehospital emergency care.

Methods

A quantitative intervention study on ambulance care was conducted in the north of Sweden. The ambulance used for the intervention group (n=30) was equipped with an electrically heated mattress on the regular ambulance stretcher whereas for the control group (n=30) no active heat was provided on the stretcher. Outcome variables were measured as thermal comfort on the Cold Discomfort Scale (CDS), subjective comments on cold experiences, and finger, ear and air temperatures.

Results

Thermal comfort, measured by CDS, improved during the ambulance transport to the emergency department in the intervention group (p=0.001) but decreased in the control group (p=0.014). A significant higher proportion (57%) of the control group rated the stretcher as cold to lie down compared to the intervention group (3%, p<0.001). At arrival, finger, ear and compartment air temperature showed no statistical significant difference between groups. Mean transport time was approximately 15 minutes.

Conclusions

The use of active heat from underneath increases the patients’ thermal comfort and may prevent the negative consequences of cold stress.

Effect evaluation of a heated ambulance mattress-prototype on body temperatures and thermal comfort--an experimental study

Background

Exposure to cold temperatures is, often, a neglected problem in prehospital care. One of the leading influences of the overall sensation of cold discomfort is the cooling of the back. The aim of this study was to evaluate the effect of a heated ambulance mattress-prototype on body temperatures and thermal comfort in an experimental study.

Method

Data were collected during four days in November, 2011 inside and outside of a cold chamber. All participants (n = 23) participated in two trials each. In one trial, they were lying on a stretcher with a supplied heated mattress and in the other trial without a heated mattress. Outcomes were back temperature, finger temperature, core body temperature, Cold Discomfort Scale (CDS), four statements from the state-trait anxiety – inventory (STAI), and short notes of their experiences of the two mattresses. Data were analysed both quantitatively and qualitatively. A repeated measure design was used to evaluate the effect of the two mattresses.

Results

A statistical difference between the regular mattress and the heated mattress was found in the back temperature. In the heated mattress trial, the statement “I am tense” was fewer whereas the statements “I feel comfortable”, “I am relaxed” and “I feel content” were higher in the heated mattress trial. The qualitative analyses of the short notes showed that the heated mattress, when compared to the unheated mattress, was experienced as warm, comfortable, providing security and was easier to relax on.

Conclusions

Heat supply from underneath the body results in increased comfort and may prevent hypothermia which is important for injured and sick patients in ambulance care.

Patients' experiences of cold exposure during ambulance care

Background

Exposure to cold temperatures is often a neglected problem in prehospital care. Cold exposure increase thermal discomfort and, if untreated causes disturbances of vital body functions until ultimately reaching hypothermia. It may also impair cognitive function, increase pain and contribute to fear and an overall sense of dissatisfaction. The aim of this study was to investigate injured and ill patients’ experiences of cold exposure and to identify related factors.

Method

During January to March 2011, 62 consecutively selected patients were observed when they were cared for by ambulance nursing staff in prehospital care in the north of Sweden. The field study was based on observations, questions about thermal discomfort and temperature measurements (mattress air and patients’ finger temperature). Based on the observation protocol the participants were divided into two groups, one group that stated it was cold in the patient compartment in the ambulance and another group that did not. Continuous variables were analyzed with independent sample t-test, paired sample t-test and dichotomous variables with cross tabulation.

Results

In the ambulance 85% of the patients had a finger temperature below comfort zone and 44% experienced the ambient temperature in the patient compartment in the ambulance to be cold. There was a significant decrease in finger temperature from the first measurement indoor compared to measurement in the ambulance. The mattress temperature at the ambulance ranged from −22.3°C to 8.4°C.

Conclusion

Cold exposure in winter time is common in prehospital care. Sick and injured patients immediately react to cold exposure with decreasing finger temperature and experience of discomfort from cold. Keeping the patient in the comfort zone is of great importance. Further studies are needed to increase knowledge which can be a base for implications in prehospital care for patients who probably already suffer for other reasons.