Akuttmedisin i ein distriktskommune
Not peer reviewed
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When medical emergencies happen, efficient organization of the emergency services and high competence among the personnel, is paramount. This dissertation contributes to the knowledge base of the medical emergency preparedness in a rural community through two studies:
Study 1 was a prospective study where all medical emergencies of the island community of Austevoll, Western Norway, were registered and analyzed. The registration was performed during a 2-year-period 2005-07.
Study 2 was a prospective study where the effects of organizing lay people in first responder teams to respond in acute cardiac emergencies, were investigated.
Study 1: Few studies exist with systematically collected material on medical emergencies and their management, at a community level. This results in inferior quality of the basis for planning and development of the emergency services. The municipality of 19 Austevoll (population 4400) is a transparent society where accurate registrations would be possible to perform, thus making it possible to meet some of the knowledge shortcomings.
Study 2: In 2002 local enthusiasts, in cooperation with a local dealer of medical equipment, deployed automated electronic defibrillators (AEDs) in Austevoll. In collaboration with the local health services, the project was modified so it could also serve as a research study. Due to scarce literature on the subject, we undertook this project, with the double aim of finding out, firstly, if such first responder teams may be sustainable over a long time period, and secondly, whether lives might be saved by a project like this.
Methods and materials
Study 1: A medical emergency was defined as an incident where the general practitioner (GP) judged it necessary to take immediate medical action. During a 2-year time period all incidents were recorded GPs and ambulance personnel. The topics were evaluation of seriousness at the notification of the incident and thereafter by the physical examination of the patient, medical treatment, evaluation of practical work conditions and practical measures taken.
Study 2: AEDs were deployed in the islands of Hundvåkøy and Bakkasund and two concentrations of industry in Austevoll, and the project period was five years. Around 10 first responders in each of the two islands and each of the two workplaces were trained in basic cardiopulmonal resuscitation and defibrillation. Questionnaires were collected from each first responder every year, concerning different aspects of self-perceived mastering of the task. In addition, incidents of suspected myocardial infarction or cardiac arrest were recorded prospectively.
Study 1: There were 236 incidents, comprising 240 patients. This corresponds to an annual incidence rate of 27 per 1 000 inhabitants. 84 % of cases concerned acute disease and 16 % were acute injuries. 62 different ICPC-diagnoses were registered as being the causes of the incidents. In 71 % of cases, the emergency occurred in the patient’s home or other dwelling. The initial treatment of the patient was started at this location in 63% of the events. Airway measures, including administration of O2, venous cannulation, ECG recording and/or monitoring of cardiac rhythm and parenteral administration of drugs were the most frequent emergency medical actions. The GP evaluated the physical working condition in the emergency scene not to be satisfactory in 18% of the events,and non-technical communication problems concerning the incident was reported in 26%. Around four out of ten episodes were downgraded in seriousness between the evaluation stages, and about one out of ten were upgraded while about half of the patients were deemed to be in unchanged degree of seriousness. Of the diagnostic groups, acute abdominal cases had the highest probability of being upgraded between stages. The aggregated diagnostic group of syncopes, seizures, intoxications and traumas had the highest probability of being downgraded. The main reason for upgrading was lack of necessary information at the stage of call. Real patient deterioration between stages was the reason for upgrading in a minority of the cases.
Study 2: All the layperson groups were functioning throughout the study period. Questionnaire responses indicated that the first responders had a reasonable degree of motivation and self-evaluated competence. However, wear-out effects among the participants were considerable, as judged by a considerable number of withdrawals of the first responders towards the end of the study period. The first responders were called out on 24 occasions, for a total of 17 patients. No case of primary ventricular fibrillation happened during the study. The number of acute myocardial infarctions was also unexpectedly low.
Study 1 Pre-hospital emergency medicine is very diverse, and is not characterized by a minority of core conditions. By triage in pre-hospital emergency medicine downgrading of the evaluated seriousness of the patients´ clinical condition is prevalent. Corresponding upgrading is not so often the case, but the potential serious consequences of such initial undertriage should lead clinicians to scrutinize such upgradings closely. The important proportion of upgradings and downgradings emphasizes the need for a doctor to be present at the scenes of medical emergencies. The high rate of problems of physical working conditions at scenes of medical emergencies, and of problems of communication between the GPs and the emergency communication centres are reasons for concerns.
Study 2: The first responder teams were functioning for almost five years, but were prone to considerable attrition towards the end of the study period. From the viewpoint of medical endpoints, the project was unsuccessful. The small scale prevents us from drawing firm conclusions as to whether an organization like this might be suitable for other remote areas of Norway. The experiences from the project may still inform further initiatives like this.
Study 1: The combination of a relatively high frequency of medical emergencies in the community, a high diversity of diagnoses lying at the heart of the events, and a high degree of uncertainty as to how serious the individual emergency turns out to be, should bear direct and strong implications on how the attribution of roles between GPs and ambulance personnel ought to be in pre-hospital emergency medicine.
Study : First responder groups ought not to be independent actors in the professional emergency organization of the local communities, but should complement the professionals. First responder groups need significant and continuous follow-up from the municipal health services.