Researchers at Karolinska Institutet have evaluated dispatching drones equipped with automated external defibrillators (AED) to patients with suspected cardiac arrest. In more than half of the cases, the drones were ahead of the ambulance by an average of three minutes. The drone-delivered defibrillator was used in a majority of the cases which proved to be cardiac arrests. The results have been published in The Lancet Digital Health.
“The use of an AED is the single most important factor in saving lives. We have been deploying drones equipped with AED since the summer of 2020 and show in this follow-up study that drones can arrive at the scene before an ambulance by several minutes. This lead time has meant that the AED could be used by people at the scene in several cases,” says Andreas Claesson, Associate Professor at the Center for Cardiac Arrest Research at the Department of Clinical Research and Education, Södersjukhuset, Karolinska Institutet, and principal investigator of the study.
Every year, around 6000 people in Sweden suffer a sudden cardiac arrest, but only a tenth of those affected survive. Although an early shock with a AED can dramatically increase the chance of survival and there are tens of thousands of AED in the community, they are not available in people’s homes where most cardiac arrests occur.
Since 2020, in an effort to cut the time to defibrillation with an AED, Karolinska Institutet, together with Region Västra Götaland, SOS Alarm and the drone operator Everdrone, have tested the possibility of dispatched an AED-carrying drone at the same time as an ambulance is alerted. The project covered an area of approximately 200 000 people in western Sweden. An initial study conducted in the summer of 2020 in Gothenburg and Kungälv showed that the idea was feasible and safe.
“This more comprehensive and follow-up study now shows in a larger material that the methodology works throughout the year, summer and winter, in daylight and darkness. Drones can be alerted, arrive, deliver AED, and people on site have time to use the AED before the ambulance arrives,” says Sofia Schierbeck, PhD student at the same department and first author of the study.
In the study, drones delivered a AED in 55 cases of suspected cardiac arrest. In 37 of these cases, the delivery took place before an ambulance, corresponding to 67%, with a median lead of 3 minutes and 14 seconds. In the 18 cases of actual cardiac arrest, the caller managed to use the AED in six cases, representing 33%. A shock was recommended by the device in two cases and in one case the patient survived.
“Our study now shows once and for all that it is possible to deliver AED with drones and that this can be done several minutes before the arrival of the ambulance in connection with acute cardiac arrest,” says Andreas Claesson. “This time saving meant that the healthcare emergency centre could instruct the person who called the ambulance to retrieve and use the AED in several cases before the ambulance arrived.”
The research was mainly funded by the Swedish Heart-Lung Foundation.
Scientists in the Netherlands have developed a special EEG cap which can diagnose stroke in the ambulance, allowing the patient to receive appropriate treatment faster. The research is published in the journal Neurology.
Every year, millions of people worldwide suffer an ischaemic stroke, the most common type of stroke, when a blood clot blocks a blood vessel of the brain, causing a part of the brain to receive no or insufficient blood. Prompt treatment is crucial to prevent permanent disability or death.
Neurologist Jonathan Coutinho, Technical Physician Wouter Potters and professor of Radiology Henk Marquering, all from Amsterdam UMC, invented the brain-wave cap, which allows an EEG to be carried out in the back of an ambulance. This shows whether there is an ischaemic stroke and whether the blocked cerebral blood vessel is large or small.
This distinction determines the treatment: in case of a small ischaemic stroke, the patient receives a blood thinner, and in case of a large ischaemic stroke, the blood clot must be removed mechanically in a specialised hospital. “When it comes to stroke, time is literally brain. The sooner we start the right treatment, the better the outcome. If the diagnosis is already clear in the ambulance, the patient can be routed directly to the right hospital, which saves valuable time,” says Coutinho.
Jonathan Coutinho said: “Our research shows that the brain-wave cap can recognise patients with large ischaemic stroke with great accuracy. This is very good news, because the cap can ultimately save lives by routing these patients directly to the right hospital.”
Between 2018 and 2022, the smart brain-wave cap was tested in twelve Dutch ambulances, with data collected from almost 400 patients. The study shows that the brain-wave cap can recognise patients with a large ischaemic stroke with great accuracy. “This study shows that the brain-wave cap performs well in an ambulance setting. For example, with the measurements of the cap, we can distinguish between a large or small ischaemic stroke,” adds Coutinho.
In order to develop the brain-wave cap into a product and bring it to the market, TrianecT, an Amsterdam UMC, spin-off company was founded in 2022. In addition, a follow-up study (AI-STROKE) is currently ongoing in which even more measurements are collected in order to develop an algorithm for improved recognition of a large ischaemic stroke in the ambulance. The Dutch Heart Foundation has also recognised the importance of this research and has made 4 million euros available for large-scale research into faster treatment of ischaemic stroke.
The Law Society of South Africa (LSSA) has urged members of the public and civic associations to formally object to proposed amendments to the Road Accident Fund Act which, if approved, will have “dire consequences” for all South African road users.
The draft amendment bill was gazetted earlier this month by the transport minister. It proposes major changes to how the fund operates and how it will pay claims.
According to the LSSA, it proposes significant changes to the existing law, including removing the rights of drivers, passengers and pedestrians to claim compensation for injuries they have suffered. Instead, it proposes that the fund will only provide significantly reduced “social benefits”.
And, says the LSSA, an innocent injured party would still be denied the common law claim against the guilty party for the balance of his or her loss.
Yet all road users contribute directly or indirectly to the fund through the fuel levy, estimated to be about R45-billion a year.
“The poor and disempowered, who make up the vast majority of claimants and who are compelled to use public transport, will bear the brunt of the consequences of these amendments. They will be forced into the public health system, as the prescribed tariffs will not cover the actual costs incurred at a private hospital. Under the present system, many receive treatment at dedicated private healthcare facilities,” the LSSA says in its statement.
Claimants will also not receive any lump sum payments and, if they are not able to produce a payslip, it was unlikely that they would receive compensation for loss of earnings.
The LSSA said those who can afford it will be compelled to take out private accident cover for medical and other expenses as well as accident benefits.
“This is likely to be very costly, as there will be no reimbursement of expenses covered from the fund. Medical aids will more than likely exclude cover or the cost thereof will have to materially increase to preserve the funds in the pool for all members.”
The LSSA said road accident victims will be uniquely discriminated against by the proposed legislation.
“Their rights to be compensated for harm suffered by the fault of another will be taken away. Persons who suffer harm from medical negligence or are injured in train or plane or boat accidents or in shopping centres, hotels, construction sites, holiday resorts, private homes or by electrocution or pollution and by a host of other causes, have unfettered rights to seek compensation from the person or entity who caused them harm.
“Innocent motor vehicle accident victims, alone, do not have this right, despite the fact that they pay premiums to the fund.”
At present, injuries sustained in a motor car accident anywhere in South Africa by any person are covered by the Fund.
The Bill now excludes injuries suffered in motor vehicle accidents in parking areas, sports fields, farm roads, driveways, private estates, game reserves or any other private road.
People who are not citizens or permanent residents are also not covered.
Persons crossing a highway are not covered. Persons injured in a hit and run are not covered. Pedestrians, drivers and cyclist who may test over the legal limit for alcohol and their dependents are not covered.
The Bill also proposes doing away with payments for pain and suffering, loss of amenities of life, disability, disfigurement or shock.
It also does away with lump sum payments for loss of earnings or support, replacing them with monthly payments, and giving the fund the right to continually reassess its liability to continue to pay.
While at present all medical and other expenses reasonably incurred that arise directly from the accident are covered, these will now be subject to a prescribed tariff. Any future medical expenses have to be pre-authorised.
The LSSA said the Bill also largely ousts the role of the courts in determining contested claims, establishing instead alternative dispute resolution procedures followed by referral to be a yet-to-be established Road Accident Fund Adjudicator.
Co-chair of the KZN Personal Injury Lawyers Association Anthony De Sousa said the biggest issues around the Bill was what was not known, such as what “social benefits” were and what the treatment tariffs would be.
“We don’t know what we are signing up for”.
“What also worries me is the people it excludes, such as pedestrians crossing highways. They don’t do that for fun. They do it because they have no choice and are trying to get to work or home.
“They are poor people and if they are knocked down, they really need help. To exclude them is just weird.”
He said while there may be a case not to cover motorists who don’t have licences, or who are over the legal alcohol limit, the Bill also proposed that their dependents are not covered, such as a child who is injured.
“The kids are not at fault, but suddenly they have no claim.”
He said the approach seemed to be: “Let’s try and save some money”.
“We pay a lot of money to the fund in terms of the levy. If you were to take that money and take up an insurance policy, you would probably get better cover and better value for money.
“I don’t think, no matter how they change it, it won’t work until they sort out the dysfunctionality, the administrative inefficiencies in the fund. You can change it to whatever system. They cannot properly administer it and run it.
“If they did their jobs properly, the fund would be saving itself a bucket load of money.”
De Sousa said the association was presently putting together its formal response to the proposals.
Collen Msibi, spokesperson for the Department of Transport said, “The bill is out for comments. The department will welcome all views and suggestions for its consideration.”
Survivors of out-of-hospital cardiac arrest (OHCA) who received initial bystander defibrillation with a nearby automated external defibrillator (AED) reported better outcomes at 12 months after arrest compared with those initially defibrillated by paramedics, according to a new study from Monash University which appears in Heart.
The retrospective study recruited adult non-traumatic OHCA with initial shockable rhythms between 2010 and 2019. Survivors at 12 months after arrest were invited to participate in structured telephone interviews. Outcomes were identified using the Glasgow Outcome Scale-Extended (GOS-E), EuroQol-5 Dimension (EQ-5D), 12-Item Short Form Health Survey and living and work status-related questions.
Of 6050 patients, 3211 (53.1%) had a pulse on hospital arrival, while 1879 (31.1%) were discharged alive. Survival rates were highest with bystander defibrillation (52.8%), followed by dispatched first responders (36.7%) and paramedics (27.9%). Of the survivors, 1802 (29.8%) survived to 12-month post-arrest; of these 1520 (84.4%) were interviewed. 1088 (71.6%) were initially shocked by paramedics, 271 (17.8%) by first responders and 161 (10.6%) by bystanders. Bystander-shocked survivors reported higher rates of living at home without care (87.5%), upper good recovery (GOS-E=8) (41.7%) and EQ-5D visual analogue scale (VAS) ≥ 80 (64.9%) compared with first responder and paramedics, respectively. After adjustment, initial bystander defibrillation was associated with higher odds of EQ-5D VAS ≥ 80 (adjusted OR (AOR) 1.56), good functional recovery (GOS-E ≥ 7) (AOR 1.53), living at home without care (AOR 1.77) and returning to work (AOR 1.72) compared with paramedic defibrillation.
Gogo Nothembile Fanti (76) says she suffers from a heart condition and every time her grandchildren call an ambulance, they are told to wait, but it never arrives. She is one of about 40 patients – mostly older persons – sleeping on the floor and in chairs at All Saints Hospital in Ngcobo in the Eastern Cape during Spotlight’s visit on 30 January. They are all waiting for an ambulance to take them to referral hospitals such as Nelson Mandela Academic Hospital and Bedford Hospital about 60 kilometres away in Mthatha. They come from various villages around Ngcobo.
Fanti, like many other patients, says they are forced to sleep there overnight as the free transport provided by the hospital leaves at the crack of dawn.
“I had to call my neighbour to [bring] me here, otherwise I could have died waiting for the ambulance. They told me that I have to be taken to Mthatha to see a specialist, but having to sleep under these conditions at my age is a terrible experience,” she says.
An old problem
The challenges with patient transport, specifically emergency medical transport in the Eastern Cape, are not new. Spotlight has previously reported on the issue here, here, and here.
In October last year, Eastern Cape Health MEC Nomakosazana Meth in a response to a written question in the provincial legislature by DA MPL Jane Cowley said that there are 84 Emergency Medical Services (EMS) bases in the Eastern Cape – 16 of those are in the Chris Hani District where All Saints Hospital is situated.
Based on the numbers Meth provided, the district also has the highest vacancy rate – 65%. This means of the 796 posts available, there were 518 vacancies for EMS staff at the time of her response in October. Overall, for the whole province, the total posts were 3 269, but 1 202 were vacant at the time.
The province needs 671 ambulances based on its population but has 447 ambulances of which only 200 were rostered, meaning they were in service at the time. In Chris Hani District, they need at least 72 ambulances but only have 62 of which just 38 were rostered and on the road to provide a service.
Staff shortages and ambulances undergoing maintenance are among the reasons why there are not enough ambulances rostered in the province. Not one of the 84 EMS bases in the province complied with the national EMS regulations for personnel numbers.
According to the DA’s provincial health spokesperson, Jane Cowley, there are 150 ambulances at any given time in for repairs. “The average turnaround time for repairs is a shocking 100 days – this is because they use the Government Fleet Management Services, who are owed in excess of R300 million by the [provincial health department] so they really don’t prioritise ambulance repairs.” She says the DA has been calling for the decentralisation of ambulance repairs and the development of public-private partnerships, which the party believes would speed up repair turnaround times dramatically.
Shouldering the burden
Providing some perspective on the impact this has on services and patient lives, a doctor says there are some districts where, at times, there is only one paramedic on duty per shift (the doctor spoke to Spotlight on condition of anonymity given the risks of reprisals from the health department). “When there is a serious call from opposite ends of the district, then you have to wait for the paramedic to deal with the one case, then come to the second. Patients in hospitals are deemed ‘less serious’ than if they are on the roadside. So, patients can wait for hours in a district hospital before being referred to a tertiary hospital. We recently had an elderly man with wet gangrene on his foot who waited in a casualty for two days. Then he died,” the doctor says.
The doctor says they often have a full casualty unit on Saturday nights. At times there may be four patients waiting for a referral. They may have gunshot wounds, been stabbed in the neck, and assaulted with a head injury. The casualty fills up as time passes and the number of patients waiting for referrals now grew by three, while the other four are still waiting in casualty. The three may be all orthopaedic patients. The doctor will ask the nurse about the patients and is told EMS said “no ambulances available”. “Maybe you have the energy to paste this update on the EMS WhatsApp group. Maybe you try to phone someone yourself to escalate this issue. Maybe someone is able to contact the provincial office and request a private ambulance to assist. But by morning, there are still six patients waiting… then one dies. The oncoming team will now have to re-discuss these patients with the new team at the referral centre. The same thing happens day after day… patients miss appointments, have to be re-discussed, get a new date due to the perseverance of the doctors, then maybe miss another date due to EMS not being available… It is extremely exhausting for all concerned,” the doctor says.
According to two paramedics (who also spoke on condition of anonymity), they struggle with inadequate equipment in EMS vehicles. This, coupled with poor road infrastructure, often puts them under enormous pressure, they say. “Cellphone network also disappears during loadshedding and this makes it impossible for patients to reach our services,” says one of the paramedics. “When we eventually arrive at the accident scene or at a sick patient, we are often met with insults from frustrated patients who said they’ve been trying to get hold of an ambulance for hours. Often, they forget about the challenges we face in trying to get to them on time,” he said.
Three-phased plan – yet to be financed
Meth in her parliamentary response last year said, “The[se] frequent transfers of patients put a heavy burden on the emergency medical services as there are no ambulances to do inter-facility transfers and therefore the emergency ambulances are used to transfer patients from hospitals to other hospitals over long distances with no ambulances left for emergency response at community level.” She said this is why there are often poor ambulance response times or no response at all.
In an attempt to address this, the provincial health department is working on a three-phased EMS plan targeting 28 hospitals across districts – among them All Saints.
This plan, however, will need funding to get off the ground.
Explaining the department’s three-phased plan, provincial health spokesperson Yonela Dekeda last week said the department plans to recruit additional personnel as funding becomes available and so did not provide timeframes. She says phase one is aimed at providing a dedicated inter-hospital transfer ambulance on a day-shift basis at the 28 priority hospitals. They aim to appoint 120 new staff members for this.
In phase two, the department wants to appoint an additional 120 personnel to make the day service a twenty-four-hour service and phase three is to extend this to other hospitals and provide them with the personnel needed.
But, says Dekeda, the department will need R27 million and they expect funding only to be made available in the 2023/24 financial year.
Working to address EMS challenges
Meanwhile, she says, the department has been working to address the many challenges facing EMS in the province and there are some improvements. “These include the response rate to priority 1 calls (life-threatening calls). Over the past three quarters – ending December 2022 – the department has been meeting its targets for priority 1 calls by responding within 30 minutes (urban areas) and 60 minutes (rural areas).” She didn’t however specify what percentage of calls met these targets.
According to her, the department has taken a developmental approach to achieve compliance with the national EMS regulations. She says over the next three years there will be continued investments in infrastructure, equipment, staffing, and vehicles to promote compliance with the ideal promulgated in the regulations.
“We have purchased an additional 50 ECG monitors at a cost of R19 million to supplement the equipment in our ambulances as required by the regulations. About R15 million has been allocated to improving the infrastructure at selected EMS stations around the province and an additional allocation is expected in the next financial year to support the strategy,” she says.
In the current financial year, she says, the Engcobo Local Service Area where All Saints Hospital is located was allocated two intermediate life support practitioners.
Dekeda says the department’s priority remains emergency patient care, so the majority of the current resources are still allocated to this.
“We are using our staff interchangeably between planned patient transport and the emergency transport service. One will understand that the planned patient transport works on weekdays (Monday to Friday) while emergency ambulance services are a 7-day operation, 24 hours a day. We are committed to increasing the number of staff on the emergency transport and then developing a separate staff complement for the planned patient transport service.”
Dekeda also says recruiting more staff is coupled with interventions to have the district hospitals offer the appropriate package of services, which will reduce the number of trips transferring patients. She says by employing dedicated teams to manage transfers of patients at the 28 priority hospitals as part of the three-phased plan, the hope is to improve the overall responsiveness of the ambulance fleet.
“We will continue with this recruitment in the next financial year and also focus on the operational staff to assist with the transfers of critical patients. All Saints is one of the district hospitals that will benefit,” she stresses.
“A total mess”
But some Eastern Cape residents remain sceptical.
Responding to the new plans, activist and community leader from Xhora Mouth, Phumzile Msaro says they are tired of empty promises. “This EMS problem is going to be with us for a long time as long as there are still unreliable people at the top. Every day we are faced with challenges as rural dwellers. Just yesterday (09 February), I called an ambulance for an elderly villager from Xhora Mouth who had fits. The assistants at the call centre lied and said the ambulance was on its way but we waited all day, only for the ambulance to arrive at 7 pm after a number of frantic calls throughout the day. The elderly person only managed to arrive and get assistance at Madwaleni Hospital at 9 pm. We keep hearing about all these so-called plans but nothing gets implemented on the ground. It’s a total mess,” he says.
Cowley echoes these sentiments. She says due to ambulance shortages and the severe shortage of EMS personnel, especially advanced life support paramedics, ambulance turnaround times are very slow, particularly in rural areas. “People can wait up to a day for an ambulance and sometimes that is too late. They have many plans but cannot seem to implement them as there is no political will to do so. It’s just a talk shop. In all my extensive oversight visits, the constant and main complaint is the lack of or slow ambulance service.”
Patients hospitalised with fractures typically receive low-molecular-weight heparin to prevent life-threatening blood clots. A new clinical trial, however, found that inexpensive over-the-counter aspirin is just as effective. The findings, published today in the New England Journal of Medicine, may lead surgeons to change their practice and administer aspirin to these patients.
With more than 12 000 patients, the multi-centre randomised clinical trial is the largest trial ever conducted on orthopaedic trauma patients. This multidisciplinary collaboration between orthopaedic surgeons and trauma surgeons points to the importance of evaluating techniques used to prevent post-surgical complications, like blood clots and infections, through high-quality, head-to-head comparison studies.
“Many patients with fractures will likely strongly prefer to take a daily aspirin over receiving injections after we found that both give them similar outcomes for prevention of the most serious outcomes from blood clots,” said the study’s principal investigator Robert V. O’Toole, MD. “We expect our findings from this large-scale trial to have an important impact on clinical practice that may even alter the standard of care.”
Patients who experience fractures that require surgery are at increased risk of developing blood clots, including life-threatening pulmonary embolisms. Current guidelines recommend prescribing low-molecular-weight heparin (enoxaparin) to prevent these clots, although smaller clinical trials in total joint replacement surgery suggested a potential benefit of aspirin as a less-expensive, widely available option.
The study enrolled 12 211 patients with leg or arm fractures that necessitated surgery or pelvic fractures regardless of the treatment. Half were randomised to 30mg of injectable enoxaparin twice daily. The other half received 81mg of aspirin twice daily. Patients were followed for 90 days to measure health outcomes from the two treatments.
The main finding of the study was that aspirin was “non-inferior,” or no worse than low molecular-weight heparin in preventing death from any cause – 47 patients in the aspirin group died, compared with 45 patients in the heparin group. For other important complications, the researchers also found no differences in pulmonary embolisms between the two groups. The incidence of bleeding complications, infection, wound problems, and other adverse events from the treatments was also similar in both groups.
Of all the outcomes studied, the only potential difference noted was in deep vein thrombosis. This condition was relatively uncommon in both groups as it occurred in 2.5% of patients in the aspirin group, and in 1.7% of patients in the heparin group.
“This relatively small difference was driven by clots lower in the leg, which are thought to be of less clinical significance and often do not require treatment,” said study co-principal investigator Deborah Stein, MD, MPH.
“Many patients don’t like giving themselves injections. It’s not fun in terms of giving the actual injection because it burns, and your stomach tends to bruise more easily compared to aspirin,” said Debra Marvel, a 53-year-old from Columbia, MD, who served as a patient advisor on the study. She received Lovenox (low-molecular-weight heparin) after her legs were crushed in a 2015 pedestrian accident, requiring multiple surgeries at the University of Maryland Shock Trauma Center. “Patients also prefer aspirin because Lovenox can be expensive based on insurance.”
“An estimated one million Americans are hospitalised each year with extremity fractures, and this new finding could help prevent potentially fatal blood clots in these patients using a medication that is cheaper and far easier to administer,” said Mark T. Gladwin, MD, Vice President for Medical Affairs, University of Maryland, Baltimore, and the John Z. and Akiko K. Bowers Distinguished Professor and Dean, University of Maryland School of Medicine. “Given these important results, we can expect the guidelines for the prevention of blood clots to be revised to include the option of aspirin for patients with traumatic bone fractures.”
A trapped mountaineer survived after enduring 16 frigid hours wedged in a crevasse on a mountain in Alaska. The difficult extraction and subsequent critical care are examined in the journal Wilderness & Environmental Medicine. This compelling case study highlights the distinguishing factors that led to the successful outcome, such as continuing even when survival from severe hypothermia seems impossible.
The mountaineer was wedged about 20 metres deep in the crevasse, waiting 4.5 hours for a rescue team to arrive, followed by an 11.5-hour extrication process. His condition deteriorated and he eventually lost consciousness. Even though the rescue team collectively felt there was little or no chance of survival, they continued rescue efforts until the victim was extricated from the crevasse. He was almost immediately placed in a hypothermia wrap with active warming, loaded onto a rescue helicopter, and transported to a hospital in Fairbanks, Alaska. He was released after 14 days and made a full recovery.
“This case documents the heroic, persistent and expert rescue efforts of a group of people dedicated to saving lives. After conferring with the chief rescuer and chief of medical personnel, we pulled together our collective insights about the challenges of extracting climbers from extremely confined spaces and providing medical care to those who have had extended cold exposure,” explained lead investigator Gordon G. Giesbrecht, PhD, professor at the University of Manitoba.
Their recommendations build on lessons learned from a previously published case study of a helicopter pilot who died after being trapped in an icy crevasse for only four hours. In that paper, Dr Giesbrecht identified the need to develop processes for search and rescue personnel to prevent circum-rescue collapse, which is a complex physiological response to extreme cold that is worsened by improper handling of the patient. He cautioned that rescuers should be trained with the principle that the colder the victim is, the more care is required to perform horizontal extrication as gently as possible. Adding a few minutes for gentle handling and to reposition will not significantly increase cold exposure, but will greatly minimise the chance of rescue collapse.
“Responders should be aware of the causes, symptoms, and prevention of rescue collapse. Training should include techniques for transitioning a victim gently from vertical to a horizontal supine or, for narrower passages, to a lateral decubitus position. Even if a victim has to be hauled up in a vertical position, a simple technique using a sling or rope under the knees allows a simple, gentle and horizontal extrication from the crevasse to the surface,” noted Dr Giesbrecht.
This case emphasised the need to continue extrication and treatment efforts for a cold patient even when survival with hypothermia seems impossible. It also underscored the need for rescue teams to pre-plan equipment and procedures specific to crevasse rescue of potentially cold patients.
This case highlights an important mix of preventive and resuscitative lessons and recommendations regarding crevasse rescue in an isolated location:
Urging climbers to rope up for glacier travel in areas with known and possible crevasses.
Making sure that any rescuers who descend into crevasses are continuously observed by someone who remains on the surface and has radio contact to call for immediate assistance.
Recognizing that respirations are often more easily detected than pulses.
Trying unorthodox extrication methods when necessary.
Rescue teams deployed for crevasse rescues should carry kits with a pneumatic hammer-chisel (important for extrication), a tripod and winch, a hypothermia wrap made of a sleeping bag and chemical heating blankets, onboard oxygen supply with an adapter that connects to nasal prongs or a patient’s mask, a mechanical chest compression device, an automated external defibrillator, and IV saline with a fluid warmer. The Denali National Park and Preserve mountaineering rangers now include such kits in their rescue aircraft.
The investigators plan to submit a standardised rescue process based on these recommendations for publication after completing field testing in the summer of 2023.
When asked about what he considered the most crucial factor for survival, Dr Giesbrecht stressed that rescuers should never give up even when the patient’s survival with hypothermia seems impossible.
In a study published in JAMA Network Open, researchers found that after a visit to the ED, many opioid overdose patients carried naloxone, which helps reverse opioid overdoses, which could save their lives in the event of a future overdose.
About 70% of current overdose deaths in the US involve opioids, which means that many of them could be prevented with naloxone. Naloxone is an opioid antagonist, blocking the effect of opioids in overdoses and able to save lives when used in time. It is easy to carry and use, and studies have demonstrated that laypeople can administer it safely and effectively to reverse overdoses.
However the people most likely to witness an overdose, including opioid users and their friends and relatives, may not be able to easily obtain naloxone. Strategies are needed to increase uptake, carrying, and administration of naloxone, especially among at-risk individuals in the community who may not be engaged in routine health care or with community naloxone distribution efforts.
Many at-risk individuals find themselves in the emergency departments (ED), either because of an overdose or other complications of substance use. The Perelman School of Medicine’s Anish Agarwal, an assistant professor of emergency medicine, and Margaret Lowenstein, an assistant professor of medicine, recently examined the potential for ED visits as a critical, reachable moment to engage high-risk individuals in overdose prevention. The team reached out to at-risk patients prescribed naloxone in the ED to understand whether they had obtained their naloxone during or after their ED visit, whether they were carrying it, and their plans to carry it in the future.
The survey asked patients about their experiences and perceptions following the ED encounter related to accessing, using, and carrying naloxone. Most of the patients did not carry naloxone prior to their ED, yet over a third reported having a personal history of an overdose requiring naloxone, and more than a quarter had used naloxone to reverse an overdose for another person in the past. Approximately half of the patients said that they were carrying naloxone after their ED visit, and two-thirds planned to continue carrying. And of patients not carrying naloxone prior to their ED visit, 54% reported a plan to continue carrying it in the future.
Researchers at MIT have found the ideal size for injectable nanoparticles that could slow traumatic internal bleeding, buying more time for a patient to reach a hospital for further treatment.
In a rat study, the researchers showed that polymer nanoparticles particles in an intermediate size range, (about 150nm in diameter) were the most effective at stopping bleeding. These particles also were much less likely to travel to the lungs or other off-target sites, which larger particles often do. The results were published in ACS Nano.
“With nano systems, there is always some accumulation in the liver and the spleen, but we’d like more of the active system to accumulate at the wound than at these filtration sites in the body,” said senior author Paula Hammond, Professor at MIT.
Nanoparticles that can stop bleeding, also called haemostatic nanoparticles, can be made in a variety of ways. One of the most commonly used strategies is to create nanoparticles made of a biocompatible polymer conjugated with a protein or peptide that attracts platelets, the blood cells that initiate blood clotting.
In this study, the researchers used a polymer known as PEG-PLGA, conjugated with a peptide called GRGDS, to make their particles. Most of the previous studies of polymeric particles to stop bleeding have focused on particles ranging in size from 300–500nm. However, few, if any studies have systematically analysed how size affects the function of the nanoparticles.
“We were really trying to look at how the size of the nanoparticle affects its interactions with the wound, which is an area that hasn’t been explored with the polymer nanoparticles used as haemostats before,” Hong says.
Studies in animals have shown that larger nanoparticles can help to stop bleeding, but those particles also tend to accumulate in the lungs, which can cause unwanted clotting there. In the new study, the MIT team analysed a range of nanoparticles, including small (< 100nm), intermediate (140–220nm), and large (500–650nm).
They first analysed the nanoparticles in the lab to see how how they interacted with platelets in various conditions, to see how well platelets bound to them. They found that, flowing through a tube, the smallest particles bound best to platelets, while the largest particles stuck best to surfaces coated with platelets. However, in terms of the ratio particles to platelets, the intermediate-sized particles were the lowest.
“If you attract a bunch of nanoparticles and they end up blocking platelet binding because they clump onto each other, that is not very useful. We want platelets to come in,” said lead author, Celestine Hong, an MIT graduate student. “When we did that experiment, we found that the intermediate particle size was the one that ended up with the greatest platelet content.”
The researchers injected the different size classes of nanoparticles into mice to see how long they would circulate for, and where they would end up in the body. As with previous studies, the largest nanoparticles tended accumulated in the lungs or other off-target sites.
The researchers then used a rat model of internal injury to study which particles would be most effective at stopping bleeding. They found that the intermediate-sized particles appeared to work the best, and that those particles also showed the greatest accumulation rate at the wound site.
“This study suggests that the bigger nanoparticles are not necessarily the system that we want to focus on, and I think that was not clear from the previous work. Being able to turn our attention to this medium-size range can open up some new doors,” Prof Hammond said.
The researchers now hope to test these intermediate-sized particles in larger animal models, to get more information on their safety and the most effective doses. They hope that eventually, such particles could be used as a first line of treatment to stop bleeding from traumatic injuries long enough for a patient to reach the hospital.
Similar outcomes were seen for patients with out-of-hospital cardiac arrest (OHCA) regardless of the advanced airway management strategy used by paramedics, results from the Taiwanese SAVE trial showed.
There was no generally no difference in clinical outcomes between groups that had the initial strategies of endotracheal intubation or supraglottic airway device insertion:
Sustained return of spontaneous circulation (ROSC) two hours after resuscitation: 26.9% vs 25.8%; survival to hospital discharge: 8.5% vs 8.4%; cerebral performance category score ≤ 2: 3.9% vs 4.8%.
Only prehospital ROSC suggested an advantage to standard endotracheal intubation (10.6% vs 6.4%), according to the researchers, whose study was published in JAMA Network Open.
Endotracheal intubation is a difficult procedure to get right. The SAVE paramedics, all experienced in both methods of advanced airway management, employed direct laryngoscopy and achieved a 77% rate of first-attempt airway success with endotracheal intubation (vs 83% with the supraglottic device). Average scene time (18.4 vs 16.9 minutes) and call-to-airway time (15.9 vs 13.9 minutes) were both longer with endotracheal intubation.
“It is unclear whether a stepwise and algorithmic endotracheal intubation training program could reduce the time in the field and the time for advanced airway insertion, and further research is warranted,” the authors said.
For the SAVE trial conducted from 2016 to 2019, researchers randomly split four EMS teams in Taipei into two clusters, each assigned to initial endotracheal intubation or supraglottic i-gel device insertion when responding to OHCAs over a biweekly period. In case the first advanced airway attempt failed, rescue airway management was allowed using a number of techniques.
The 936 OHCA patients in the study had a median age of 77 years, and 60.8% were men.
However, subgroup analysis showed that prehospital ROSC rates favoured endotracheal intubation in patients with nonshockable rhythm, nonpublic collapse, witnessed arrest, call-to-airway time under 14 minutes, and age 77 years or older.
However, different in-hospital management between groups could have affected the results. The two study arms were unequal in size, and the study could have been underpowered because of inaccurate sample size representation at the study outset. However, the researchers lamented that “even if we had realised that the sample size was inadequate at that time, we would not have been able to recruit more cases because of the outbreak of COVID.”