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Backgrounds: Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia., Methods: Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians., Results: In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores., Conclusions: Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes., Trial Registration: Not applicable., (© 2024. The Author(s).)

Background: Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field's in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement., Case Presentation: Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed., Conclusions: The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges., (© 2023. The Author(s).)

Background: Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement., Methods: Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times., Results: Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74-80% and the range of undertriage was 20-32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was "Police/fire brigade request immediate response" recorded in 4321 (22.7%) of the incidents. Criteria from the groups "Accidents" and "Road traffic accidents" were recorded in 10,875 (57.2%) incidents, and criteria from the groups "Transport reservations" and "Unidentified problem" in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records., Conclusions: Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety., (© 2021. The Author(s).)

Background: Major incidents (MI) are rare occurrences in Scandinavia. Literature depicting Scandinavian MI management is scarce and case reports and research is called for. In 2019, a trailer falling off a freight train struck a passing high-speed train on the Great Belt Bridge in Denmark, killing eight people instantly and injuring fifteen people. We aim to describe the emergency medical services (EMS) response to this MI and evaluate adherence to guidelines to identify areas of improvement for future MI management., Case Presentation: Nineteen EMS units were dispatched to the incident site. Ambulances transported fifteen patients to a trauma centre after evacuation. Deceased patients were pronounced life-extinct on-scene. Radio communication was partly compromised, since 38.9% of the radio shifts were not according to the planned radio grid and presented a potential threat to patient outcome and personnel safety. Access to the incident site was challenging and delayed due to traffic congestion and safety issues., Conclusion: Despite harsh weather conditions and complex logistics, the availability of EMS units was sufficient and patient treatment and evacuation was uncomplicated. Triage was relevant, but at the physicians' discretion. Important findings were communication challenges and the consequences of difficult access to the incident site. There is a need for an expansion of capacity in formal education in MI management in Denmark., (© 2021. The Author(s).)

Objective: Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support., Methods: Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient's next of kin and the Regional committee for medical and health research ethics approved the publication of this report., Conclusion: Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient's ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO 2 . Finally, assuming the patient is cooperative, repositioning to prone position.

Background: Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia., Methods: A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups., Results: Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO 2  < 90%) was 16.7%; 10.9% had SpO 2  < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO 2  < 90% 10 minutes post-intubation). Median SpO 2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO 2  < =90%) for patients with initial SpO 2  > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation., Conclusion: Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

Background: Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS., Methods: A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts., Results: Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template., Conclusions: Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.

The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a 'top five' in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.

Background: Helicopter EMS (HEMS) teams may perform a variety of clinical, managerial and transport functions during major incident management. Despite national and international variations in HEMS systems, the rapid delivery of HEMS personnel with advanced skills in major incident management and clinical scene leadership has been crucial to the delivery of an effective medical response at previous incidents. This document outlines the Best Practice Advice of the European HEMS and Air Ambulance Committee (EHAC) Medical Working Group on how HEMS and Pre Hospital Critical Care teams may maximise the positive impact of their resources in the event of Major Incidents., Methods: Narrative literature review and expert consensus., Results: To ensure a safe, coordinated and effective response, HEMS teams require suitable, proportionate and up to date major incident plans that are integrated into the major incident plans of other regional emergency and healthcare services. Role specific protocols, training and equipment should be adapted to the expected HEMS role in the major incident plan and likely regional threats. System and incident factors will influence HEMS utilisation during the major incident response and can include patient and staff transfer, equipment resupply, aerial assessment, search and rescue, clinical leadership and advanced care. During the recovery phase of a major incident there is a need to ensure restoration of conventional service and address the welfare of involved HEMS personnel. Standardised reporting of major incidents is strongly recommended for clinical governance, legal and research reasons., Conclusions: The rapid delivery of HEMS personnel with advanced skills in Major Incident management and clinical scene leadership is crucial to the delivery of an effective medical response at Major Incidents.

Background: There is increasing interest for quality measurement in health care services; pre-hospital emergency medical services (EMS) included. However, attempts of measuring the quality of physician-staffed EMS (P-EMS) are scarce. The aim of this study was to develop a set of quality indicators for international P-EMS to allow quality improvement initiatives., Methods: A four-step modified nominal group technique process (expert panel method) was used., Results: The expert panel reached consensus on 26 quality indicators for P-EMS. Fifteen quality indicators measure quality of P-EMS responses (response-specific quality indicators), whereas eleven quality indicators measure quality of P-EMS system structures (system-specific quality indicators)., Discussion: When measuring quality, the six quality dimensions defined by The Institute of Medicine should be appraised. We argue that this multidimensional approach to quality measurement seems particularly reasonable for services with a highly heterogenic patient population and complex operational contexts, like P-EMS. The quality indicators in this study were developed to represent a broad and comprehensive approach to quality measurement of P-EMS., Conclusions: The expert panel successfully developed a set of quality indicators for international P-EMS. The quality indicators should be prospectively tested for feasibility, validity and reliability in clinical datasets. The quality indicators should then allow for adjusted quality measurement across different P-EMS systems.

Major incidents are resource-demanding situations that require urgent and effective medical management. The possibility to extract learning from them is therefore important. Comparative analysis of information based on uniform data collection from previous incidents may facilitate learning. The Major Incident Reporting Collaborators have developed a template for reporting of the medical pre-hospital response to major incidents. The template is accompanied by an open access webpage ( www.majorincidentreporting.org ) for online reporting and access to published reports. This commentary presents the experiences from the first year of implementing the template including a presentation of the five published reports.

Pre-hospital critical care is considered to be a complex intervention with a weak evidence base. In quality improvement literature, the value equation has been used to depict the inevitable relationship between resources expenditure and quality. Increased value of pre-hospital critical care involves moving a system from quality assurance to quality improvement. Agreed quality indicators can be integrated in existing quality improvement and complex intervention methodology. A QI system for pre-hospital critical care includes leadership involvement, multi-disciplinary buy-in, data collection infrastructure and long-term commitment. Further, integrating process control with governance systems allows evidence-based change of practice and publishing of results.

Background: Structured reporting of major incidents has been advocated to improve the care provided at future incidents. A systematic review identified ten existing templates for reporting major incident medical management, but these templates are not in widespread use. We aimed to address this challenge by designing an open access template for uniform reporting of data from pre-hospital major incident medical management that will be tested for feasibility., Methods: An expert group of thirteen European major incident practitioners, planners or academics participated in a four stage modified nominal group technique consensus process to design a novel reporting template. Initially, each expert proposed 30 variables. Secondly, these proposals were combined and each expert prioritized 45 variables from the total of 270. Thirdly, the expert group met in Norway to develop the template. Lastly, revisions to the final template were agreed via e-mail., Results: The consensus process resulted in a template consisting of 48 variables divided into six categories; pre-incident data, Emergency Medical Service (EMS) background, incident characteristics, EMS response, patient characteristics and key lessons., Conclusions: The expert group reached consensus on a set of key variables to report the medical management of pre-hospital major incidents and developed a novel reporting template. The template will be freely available for downloading and reporting on http://www.majorincidentreporting.org. This is the first global open access database for pre-hospital major incident reporting. The use of a uniform dataset will allow comparative analysis and has potential to identify areas of improvement for future responses.

Background: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents., Methods: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project., Results: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately., Conclusions: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

Background: Early identification of major trauma may contribute to timely emergency care and rapid transport to an appropriate health-care facility. Several prognostic trauma models have been developed to improve early clinical decision-making., Methods: We systematically reviewed models for the early care of trauma patients that included 2 or more predictors obtained from the evaluation of an adult trauma victim, investigated their quality and described their characteristics., Results: We screened 4,939 records for eligibility and included 5 studies that derivate 5 prognostic models and 9 studies that validate one or more of these models in external populations. All prognostic models intended to change clinical practice, but none were tested in a randomised clinical trial. The variables and outcomes were valid, but only one model was derived in a low-income population. Systolic blood pressure and level of consciousness were applied as predictors in all models., Conclusions: The general impression is that the models perform well in predicting survival. However, there are many areas for improvement, including model development, handling of missing data, analysis of continuous measures, impact and practicality analysis.

Background: Field triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines., Methods: Retrospective analysis of 7 years (2001-07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity)., Results: Of the 4,659 patients included in the study, 2,221 (48%) were severely injured. TTA occurred 4,440 times, only 2,002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1,508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6-3.4, p < 0.001) compared to those correctly triaged to TTA., Conclusion: Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.