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Pesonen E, Vuorinen P, Surakka L, Lehto JT, Hoppu S. Palliative care patients in the emergency medical service: a retrospective cohort study from Finland. BMC Health Serv Res 2024; 24:543. [PMID: 38685064 PMCID: PMC11057072 DOI: 10.1186/s12913-024-10905-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/26/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Paramedics are often involved in treating palliative care patients with difficulties regarding symptom control. They report minimal training in palliative care and find decision-making difficult. This often leads to overtreatment and unnecessary transportation to the emergency department. The study's objective is to determine how much palliative patients use emergency services, how well are they recognized by paramedics and how paramedics choose care in terms of treatment and transportation. METHODS This study is a retrospective cohort study based in the Finnish Tampere University Hospital area. We included patients with a palliative care decision setting the goal of therapy as palliative intent between 1 August 2021 and 31 December 2021 and who died before 1 April 2022. From these patients, records of nurse paramedic visits were retrieved. Descriptive statistics were used to describe the data. RESULTS Paramedics visited 69 patients in 97 callouts. These callouts comprised 0.26% of the total dispatches in the study area. The most common reasons for callouts were general weakness, breathing difficulty and pain. The paramedics provided treatment in 40% of the missions. 55% of the patients were transported to the emergency department. A palliative care plan was recognized by the paramedics in 42 of the 97 callouts. A total of 38 patients were recognized as palliative care patients by the paramedics while in the cases of 31 patients, palliative care was not recognized in any dispatch. CONCLUSION Patients in palliative care cause only a minimal load on the emergency medical services, but the paramedics do not necessarily recognize them as such. This leads to the risk of overtreatment and a high transportation rate to the emergency department, which is not an ethical choice. Recognition and treatment provided to palliative care patients by the paramedics could be improved with additional training and greater availability of patient records.
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Affiliation(s)
- Eemil Pesonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
- Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland.
| | - Pauli Vuorinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland
| | - Leena Surakka
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
- Siun Sote - North Karelia Social and Health Services Joint Authority, Palliative Care Centre, Joensuu, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre, Tampere University Hospital, Tampere, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland
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Friberg H, Wisborg T. Ambulance helicopters for every emergency? Acta Anaesthesiol Scand 2020; 64:1232-1233. [PMID: 32691406 DOI: 10.1111/aas.13676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Hans Friberg
- Skåne University Hospital ‐ Intensive and Perioperative care Malmö Sweden
- Department of Clinical Sciences Anesthesiology and Intensive care, Lund University Sweden
| | - Torben Wisborg
- University of TromsøThe Arctic University of Norway Hammerfest Norway
- Department of Anaesthesia and Intensive Care Hammerfest HospitalFinnmark Health Trust Hammerfest Norway
- Norwegian National Advisory Unit on Trauma Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
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Kangasniemi H, Setälä P, Olkinuora A, Huhtala H, Tirkkonen J, Kämäräinen A, Virkkunen I, Yli‐Hankala A, Jämsen E, Hoppu S. Limiting treatment in pre-hospital care: A prospective, observational multicentre study. Acta Anaesthesiol Scand 2020; 64:1194-1201. [PMID: 32521040 DOI: 10.1111/aas.13649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/17/2020] [Accepted: 05/26/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. METHODS A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. RESULTS There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. CONCLUSION Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.
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Affiliation(s)
- Heidi Kangasniemi
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
- Emergency Medical Services Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Piritta Setälä
- Emergency Medical Services Tampere University Hospital Tampere Finland
| | - Anna Olkinuora
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
| | - Heini Huhtala
- Faculty of Social Sciences Tampere University Tampere Finland
| | - Joonas Tirkkonen
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
- Intensive Care Unit Liverpool Hospital Sydney Australia
| | - Antti Kämäräinen
- Emergency Medical Services Tampere University Hospital Tampere Finland
- Department of Emergency Medicine Department of Anaesthesia Hyvinkää District Hospital Hyvinkää Finland
| | - Ilkka Virkkunen
- Research and Development Unit FinnHEMS LtdWTC Helsinki Airport Vantaa Finland
- Emergency Medical Services Tampere University Hospital Tampere Finland
| | - Arvi Yli‐Hankala
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Department of Anaesthesia Tampere University Hospital Tampere Finland
| | - Esa Jämsen
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Centre of Geriatrics Tampere University Hospital Tampere Finland
| | - Sanna Hoppu
- Emergency Medical Services Tampere University Hospital Tampere Finland
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Kangasniemi H, Setälä P, Huhtala H, Kämäräinen A, Virkkunen I, Tirkkonen J, Yli-Hankala A, Hoppu S. Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey. Scand J Trauma Resusc Emerg Med 2019; 27:89. [PMID: 31578145 PMCID: PMC6775669 DOI: 10.1186/s13049-019-0663-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022] Open
Abstract
Background Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes. Methods A nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048). Results Fifty-nine (88%) physicians responded. Their median age was 43 (IQR 38–47) and median medical working experience was 15 (IQR 10–20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes. Conclusion Making limitation of care orders is an important but often invisible part of a HEMS physician’s work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient’s best interests. Electronic supplementary material The online version of this article (10.1186/s13049-019-0663-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heidi Kangasniemi
- Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland. .,Division of Anaesthesiology, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029 HUS, Helsinki, Finland. .,Faculty of Medicine and Life Sciences, Tampere University, FI-33014, Tampere, Finland.
| | - Piritta Setälä
- Emergency Medical Services, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Antti Kämäräinen
- Emergency Medical Services, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Ilkka Virkkunen
- Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland.,Emergency Medical Services, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Joonas Tirkkonen
- Department of Anaesthesia, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Arvi Yli-Hankala
- Faculty of Medicine and Life Sciences, Tampere University, FI-33014, Tampere, Finland.,Department of Anaesthesia, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
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Loisa E, Setälä P, Hoppu S, Tirkkonen J. Early termination of resuscitation in in-hospital cardiac arrest and impact to the outcome calculations. Acta Anaesthesiol Scand 2019; 63:1239-1245. [PMID: 31328251 DOI: 10.1111/aas.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/21/2019] [Accepted: 05/27/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Some in-hospital resuscitation attempts are assessed futile and terminated early on. We hypothesized that if these cases are reported separately, the true outcome of in-hospital cardiac arrest is better reflected. METHODS We conducted a 3-year prospective observational Utstein-style study in Tampere, Finland. All adult in-hospital cardiac arrests outside critical care areas attended by hospital's rapid response team were included. Resuscitation attempts that were terminated within 10 minutes were considered early terminations. RESULTS The cohort consisted of 199 in-hospital cardiac arrest patients. Twenty-seven (14%) resuscitation attempts were terminated early due to the presumed futility of the attempt with median resuscitation duration of 5 (4, 7) minutes. These cases and the 172 patients with full resuscitation attempt were of comparable age, sex and comorbidity. Early terminated resuscitation attempts were more often unwitnessed (63% vs. 10%, P < .001) with initial non-shockable rhythm (100% vs. 80%, P = .006) when compared with full attempts. The most frequently reported reasons for termination decisions were non-witnessed arrest presenting asystole as initial rhythm and severe acute illness. The hospital survival with good neurological outcome and 1-year survival were 30% and 25% for the whole cohort, and 34% and 29% when early terminated resuscitation attempts were excluded. CONCLUSION One-seventh of resuscitation attempts were terminated early on due to presumed futility of the attempt. Short- and long-term outcomes were 5% and 4% better when early terminated attempts were excluded from the outcome analyses. We believe that in-hospital cardiac arrest outcome is not as poor as repeatedly presented in the literature.
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Affiliation(s)
- Eetu Loisa
- Medical School Tampere University Tampere Finland
- Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
| | - Piritta Setälä
- Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
- Emergency Medical Service Tampere University Hospital Tampere Finland
| | - Sanna Hoppu
- Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
- Emergency Medical Service Tampere University Hospital Tampere Finland
| | - Joonas Tirkkonen
- Department of Emergency, Anaesthesia and Pain Medicine Tampere University Hospital Tampere Finland
- Department of Intensive Care Medicine Tampere University Hospital Tampere Finland
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Kangasniemi H, Setälä P, Huhtala H, Kämäräinen A, Virkkunen I, Jämsen E, Yli-Hankala A, Hoppu S. Out-of-hospital cardiac arrests in nursing homes and primary care facilities in Pirkanmaa, Finland. Acta Anaesthesiol Scand 2018; 62:1297-1303. [PMID: 29845604 DOI: 10.1111/aas.13152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dispatching Emergency Medical Services to treat patients with deteriorating health in nursing homes and primary care facilities is common in Finland. We examined the cardiac arrest patients to describe this phenomenon. We had a special interest in patients for whom cardiopulmonary resuscitation was considered futile. METHODS We conducted an observational study between 1 June 2013 and 31 May 2014 in the Pirkanmaa area. We included cases in which Emergency Medical Services participated in the treatment of cardiac arrest patients in nursing homes and primary care facilities. RESULTS Emergency Medical Services attended to a total of 355 cardiac arrest patients, and 65 patients (18%) met the inclusion criteria. The included patients were generally older than 65 years, but otherwise heterogeneous. Nineteen patients (29%) had a valid do-not-attempt-resuscitation order, but paramedics were not informed about it in 10 (53%) of those cases. Eight (12%) of the 65 patients survived to hospital admission and 3 (5%) survived to hospital discharge with a neurologically favourable outcome. Two patients were alive 90 days after the cardiac arrest; both were younger than 70 years of age and had ventricular fibrillation as primary rhythm. There were no survivors in nursing homes. CONCLUSIONS The do-not-attempt-resuscitation orders were often unavailable during a cardiopulmonary resuscitation attempt. Although resuscitation attempts were futile for patients in nursing homes, some patients in primary care facilities demonstrated a favourable outcome after cardiac arrest. Emergency Medical Services seem to be able to recognise potential survivors and focus resources on their treatment.
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Affiliation(s)
- H. Kangasniemi
- Research and Development Unit; FinnHEMS Ltd; WTC Helsinki Airport; Vantaa Finland
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
- Faculty of Medicine and Life Sciences; University of Tampere; Tampere Finland
| | - P. Setälä
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
| | - H. Huhtala
- Faculty of Social Sciences; University of Tampere; Tampere Finland
| | - A. Kämäräinen
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
| | - I. Virkkunen
- Research and Development Unit; FinnHEMS Ltd; WTC Helsinki Airport; Vantaa Finland
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
| | - E. Jämsen
- Faculty of Medicine and Life Sciences; University of Tampere; Tampere Finland
| | - A. Yli-Hankala
- Faculty of Medicine and Life Sciences; University of Tampere; Tampere Finland
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - S. Hoppu
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
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Setälä P, Hellevuo H, Huhtala H, Kämäräinen A, Tirkkonen J, Hoppu S. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests. Acta Anaesthesiol Scand 2018; 62:1290-1296. [PMID: 29797706 DOI: 10.1111/aas.13155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/23/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND We aimed to determine the incidence of and associated risk factors for cardiopulmonary resuscitation (CPR)-related injuries in non-survivors of out-of-hospital cardiac arrests (OHCAs) in an emergency medical service (EMS) system in which all CPR procedures are performed on scene and patients are not routinely transported to the hospital with ongoing CPR. MATERIAL AND METHODS We conducted this prospective observational study between 1 June 2013, and 31 May 2014. Data were collected from EMS datasheets and forensic autopsy records. The exclusion criteria were OHCAs due to trauma in the thoracic or abdominal area. EMS adhered to the European Resuscitation Council Resuscitation Guidelines (2010) during the resuscitation attempts. RESULTS Emergency medical service provided CPR in 280 attended OHCAs with 207 cases terminated on scene. A total of 149 patients underwent a forensic autopsy and 47% had a CPR-related injury. The most common injuries were multiple rib fractures (43%), with 22% of patients having more than eight fractured ribs. Abdominal visceral injuries or injuries related to airway management were rare. The injuries were associated with older age, male gender, initial shockable rhythm and public location of the cardiac arrest (P < .05 respectively). In the multivariable regression analysis, older age, male gender, and public location were independent predictors for injuries. There were no differences in the durations of the CPR attempt between the injured and non-injured groups. CONCLUSION Older age, male gender, and public location were independently associated with CPR-related injuries. The duration of the resuscitation attempts did not affect the incident of injuries.
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Affiliation(s)
- P. Setälä
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
- FinnHEMS Research and Development Unit; FinnHEMS Ltd; WTC Helsinki Airport; Vantaa Finland
| | - H. Hellevuo
- Department of Intensive Care; Tampere University Hospital; Tampere Finland
| | - H. Huhtala
- Faculty of Social Sciences; University of Tampere; Tampere Finland
| | - A. Kämäräinen
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
| | - J. Tirkkonen
- Department of Intensive Care; Tampere University Hospital; Tampere Finland
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - S. Hoppu
- Emergency Medical Services; Tampere University Hospital; Tampere Finland
- Department of Intensive Care; Tampere University Hospital; Tampere Finland
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Hellevuo H, Sainio M, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Good quality of life before cardiac arrest predicts good quality of life after resuscitation. Acta Anaesthesiol Scand 2018; 62:515-521. [PMID: 29315466 DOI: 10.1111/aas.13065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 04/21/2017] [Accepted: 12/06/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The survival rate of cardiac arrest patients is increasing. Our aim was to compare the quality of life before and after cardiac arrest and analyse the factors associated with outcome. METHODS All adult cardiac arrest patients admitted to the Tampere University Hospital intensive care unit between 2009 and 2011 were included in a retrospective follow-up study if surviving to discharge and were asked to return a questionnaire after 6 months. Data on patient demographics and pre-arrest quality of life were retrieved from medical records. Data are given as means (SD) or medians [Q1 , Q3 ]. We used logistic regression to identify factors associated with better quality of life after cardiac arrest. RESULTS Six months after cardiac arrest, 36% (79/222) were alive and 70% (55/79) of those patients completed the follow-up EuroQoL (EQ-5D) quality of life questionnaire. Median values for the EQ-5D before and after cardiac arrest were 0.89 [0.63, 1] and 0.89 [0.62, 1], respectively (P = 0.75). Only the EQ-5D prior to cardiac arrest was associated with better quality of life afterwards (OR 1.2; 95% CI 1.0-1.3; P = 0.02). CONCLUSIONS Quality of life remained good after cardiac arrest especially in those patients who had good quality of life before cardiac arrest.
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Affiliation(s)
- H. Hellevuo
- Department of Intensive Care Medicine; Tampere University Hospital and University of Tampere; Tampere Finland
| | - M. Sainio
- Department of Intensive Care Medicine; Tampere University Hospital and University of Tampere; Tampere Finland
- Emergency Medical Services; Department of Emergency Medicine; University of Turku and Turku University Hospital; Turku Finland
| | - H. Huhtala
- Faculty of Social Sciences; University of Tampere; Tampere Finland
| | - K. T. Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - J. Tenhunen
- Department of Surgical Sciences, Anaesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - S. Hoppu
- Department of Intensive Care Medicine; Tampere University Hospital and University of Tampere; Tampere Finland
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