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Paula Hofstetter,1,2 Hanna Schröder,1,3 Stefan K Beckers,1,3,4 Christina Borgs,1 Rolf Rossaint,1 Marc Felzen1,3,4 1Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany; 2Department of Anesthesiology, Rhein-Maas Klinikum, Würselen, Germany; 3Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany; 4Medical Direction of Aachen Fire Department, Aachen, GermanyCorrespondence: Marc Felzen, Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, Tel +49 241 8088179, Fax +49 241 82406, Email mfelzen@ukaachen.deBackground: The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device.Methods: A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter.Results: Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard.Conclusion: It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.Keywords: immobilization, trauma, emergency medicine, Canadian C-spine rule, NEXUS-criteria, tele-emergency medicine

ZusammenfassungDie Telemedizin ist in einigen Regionen Deutschlands bereits fester Bestandteil des Rettungsdienstes. Dieser Fallbericht handelt von einem Telenotarzteinsatz, bei dem die initiale Telekonsultation durch eine an der Einsatzstelle befindliche Notärztin erfolgte. Der Patient hatte eine lebensbedrohliche ventrikuläre Tachykardie mit zunehmender Kreislaufinstabilität. Dies stellte für die noch unerfahrene Notärztin eine extrem herausfordernde Einsatzsituation dar. Sie entschied sich, telemedizinische Unterstützung in Anspruch zu nehmen. So konnte sie angeleitet werden, bei dem instabilen Patienten einen i.o.-Zugang, eine medikamentöse Therapie und eine elektrische Kardioversion durchzuführen. Die Zusammenarbeit mit dem Telenotarzt ermöglichte der noch unerfahrenen Notärztin, eine leitlinienkonforme Therapie durchzuführen sowie den Patienten zeitnah stabilisiert ins Krankenhaus zu transportieren.

Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017.The aim of this work was to evaluate this project.All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students.In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year.A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.HINTERGRUND: Wiederbelebungsunterricht ist nicht in allen Schulen Deutschlands verpflichtend, dieser beschränkt sich trotz niedriger Laienreanimationsrate aktuell auf einzelne, z. T verpflichtende Projekte in unterschiedlichen Bundesländern. Aus diesem Grunde hat das Ministerium für Schule und Bildung Nordrhein-Westfalen per Runderlass im März 2017 das Projekt „Laienreanimation an Schulen in NRW“ initiiert.Ziel dieser Arbeit ist die Evaluation dieses Projekts.Alle weiterführenden Schulen in Nordrhein-Westfalen wurden zur Teilnahme am Projekt eingeladen. Aus jedem Regierungsbezirk nahmen ärztliche Partner teil, welche Wiederbelebungstrainings mit bereits bestehenden Konzepten zum Lehrer- oder Schülertraining durchführten. Nach einer 3‑jährigen Laufzeit erfolgte die Evaluation anhand von standardisierten Fragebögen für Schuldezernenten, Lehrer und Schüler.Insgesamt konnten durch das Projekt mehr als 40.000 Schüler aus 249 Schulen in NRW mit 6 unterschiedlichen Konzepten in Wiederbelebung trainiert werden. Fragen bezüglich Wiederbelebungsmaßnahmen konnten durch 85 % der Schüler richtig beantwortet werden. Die Schüler fühlen sich insgesamt sicher in Wiederbelebungsmaßnahmen. Der Investitionsbedarf für alle Schulen liegt bei einmalig zwischen 4 und 6,5 Mio. € sowie rund 340.000 € in jedem Haushaltsjahr.Eine gesetzliche Verpflichtung und Finanzierung von Wiederbelebungstrainings sind unerlässlich für eine flächendeckende Durchführung. Alle durchgeführten Konzepte sind effektiv, dementsprechend kann jede Schule ein auf ihre Bedürfnisse abgestimmtes Konzept auswählen und dieses bestenfalls gestuft anwenden. Die Schulung von Lehrern sollte gezielt auf Wiederbelebung ausgerichtet sein.

Die Anzahl der Sekundartransporte nimmt aufgrund von zunehmender Spezialisierung, Kapazitatsausgleich zwischen Intensivbehandlungsplatzen sowie fruhzeitigerer Rehabilitation stetig zu. Dies fuhrt zu einer Zunahme von Anforderungen notarztbegleiteter Sekundartransporte. Es wurde untersucht, ob die Abklarung von Sekundartransporten durch einen Notarzt in der Leitstelle den Einsatz rettungsdienstlicher Ressourcen fur Sekundartransporte optimieren kann. Es erfolgte eine retrospektive Auswertung aller durch den Telenotarzt durchgefuhrten Abklarungen von Sekundartransporten im Rettungsdienst der Stadt Aachen zwischen dem 01.01.2018 und dem 31.12.2019 sowie den dazugehorigen Anforderungsfaxen. Zusatzlich wurden alle Daten zu Anzahl und alarmierten Rettungsmitteln von Sekundartransporten ab 2013 aus dem Leitstellenrechner exportiert und in die Auswertung einbezogen. Es wurden 2333 arztliche Abklarungen von Sekundartransporten aus 2018 und 2019 analysiert sowie von 2013 bis 2019 insgesamt 10.923 Sekundartransporte erfasst. Notarztbegleitete Transporte nahmen von 2013 bis 2019 von 786 (68,2 %) auf 495 (30,5 %) signifikant ab (p

Background: Respiratory distress is one of the most common complaints of patients requiring out-of-hospital emergency services. Determining the precise discharge diagnosis in these circumstances can be challenging due to the wide range of suspected diagnoses. Moreover, these patients appear to have particularly high mortality, but little is currently known about the exact mortality rates associated with specific discharge diagnoses. Our study, therefore, aimed to determine how accurately correct diagnoses are made by EMS physicians in the out-of-hospital setting, identify examination findings that correlate with discharge diagnoses, investigate hospital mortality, and identify mortality-associated predictors.Methods: This retrospective observational study examined emergency medical service (EMS) encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). By linking out-of-hospital data to hospital records, including initial blood gas analysis, a discharge diagnosis was assigned to each EMS encounter, and the outcome was analyzed. Binary logistic regressions were used to search for associations between pathological findings and discharge diagnoses, as well as predictors of hospital mortality.Results: The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15 ≙ 100%), hypertensive crisis (28/33 ≙ 84.4%), and COPD exacerbation (114/138 ≙ 82.6%), and the lowest accuracies were observed in urinary tract infection (14/35 ≙ 40%), pulmonary embolism (8/18 ≙ 44.4%), and pneumonia (70/142 ≙ 49.3%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142 ≙ 31%) and urinary tract infection (7/35 ≙ 20%). Potential risk factors for hospital mortality identified in this study were reduced vigilance, low oxygen saturation, increasing age, blood gas analysis (BGA) results associated with metabolic acidosis, and an incorrect out-of-hospital diagnosis by the EMS physician.Conclusions: Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. The identified predictors could help in early detection of patients at risk in the future.

Der bundeseinheitliche Notarztindikationskatalog bildet die Grundlage der Notarztdisposition, bisher ohne Verbesserungen des Rettungsdienstes zu berucksichtigen. Durch Weiterentwicklungen wie die Einfuhrung des Notfallsanitatergesetzes, die Implementierung von Telemedizin sowie eine deutlich erweiterte Ausstattung der Rettungswagen (RTW) wird dem Rettungsdienst zunehmend eine gestufte Notfallbehandlung ermoglicht. Daraus resultiert die Frage, wie oft ein Notarzt heutzutage erforderlich ist und ob dieser ressourcenschonender eingesetzt werden kann. Ziel dieser Untersuchung ist eine Ersteinschatzung zum Erfordernis der Notarzte an der Einsatzstelle, basierend auf der Selbsteinschatzung der Notarzte. Die Erfordernis eines Notarztes an der Einsatzstelle, Verdachtsdiagnosen und Medikamentengaben wurden anhand einer Befragung von Notarzten im Rettungsdienst der Stadt Aachen sowie Auswertung der Notarztprotokolle im Zeitraum vom 01.12.2017 bis zum 28.02.2018 uberpruft. Daneben wurden auch Konsultationen des Telenotarztes durch einen RTW hinsichtlich Verdachtsdiagnosen und Medikamentengaben ausgewertet. Bei insgesamt 6851 erfassten Einsatzen wurden 20,6 % (n = 1410) durch den bodengebundenen Notarzt und 10,5 % (n = 721) durch den Telenotarzt unterstutzt. Die Notarzte hielten sich bei 46,7 % (n = 654) aller Notarzteinsatze fur nicht erforderlich, waren jedoch im Mittel 25 min vor Ort an der Einsatzstelle gebunden. Der haufigste Grund fur das Erfordernis des Notarztes an der Einsatzstelle waren in 29,8 % (n = 225) vital instabile Patienten. In 11 % der rettungsdienstlichen Einsatze war der Notarzt aus seiner Sicht erforderlich. Eine klare Indikationsstellung kann erreichen, dass der Notarzt aufgrund seiner hoheren Verfugbarkeit zielgerichteter eingesetzt werden kann. Ein notwendiger Arztkontakt konnte in mehr als 10,5 % der rettungsdienstlichen Einsatze mit Unterstutzung durch einen Telenotarzt realisiert werden.

Schmerzen gehoren zu den haufigsten Einsatzanlassen im Rettungsdienst und erfordern abhangig von der Schmerzintensitat eine medikamentose Intervention. Im europaischen Ausland ist die Anwendung von opiathaltigen Substanzen zur Schmerzlinderung durch geschultes und zertifiziertes Rettungsdienstpersonal ublich (z. B. Schweiz, Niederlande), wahrend sie in Deutschland aufgrund des Betaubungsmittelgesetzes nur durch (Not‑)Arzte bzw. auf deren Weisung erlaubt ist. Vergleich von 2 unterschiedlichen algorithmenbasierten Analgesiekonzepten mit arztlicher Konsultation hinsichtlich Anwendungssicherheit, Vertraglichkeit sowie Wirksamkeit. In einer retrospektiven Kohortenstudie an 2 Standorten wurden algorithmenbasierte Analgesiekonzepte – ein telefonisches Callback-Verfahren (Rettungsdienstkooperation in Schleswig-Holstein: RKiSH) und ein telenotarztbasiertes Konzept (Rettungsdienst Stadt Aachen: RDAC) uber einen Zeitraum von 2 Jahren untersucht. Innerhalb eines Beobachtungszeitraumes von 2 Jahren gab es im Bereich der RKiSH insgesamt 878 (2016: 428, 2017: 450), im RDAC 728 (2015: 226, 2016: 502) Analgetikagaben. Callback vs. Telemedizin: anfangliche NRS-Scores lagen bei 9 [8–10] und 8 [6–9] (p

Each year there are 7.3 million emergencies for the German rescue service, trend rising and around 59% of the emergency patients are treated by paramedics only; however, most of the studies focus on physicians, while their practical skills at the scene are rarely necessary. Accordingly, the responsibility for the patient lies with the paramedics most of the time. Their duty is to execute life-saving measures, stabilize the patient for the transport and the regular documentation of the operation. Retrospectively, the emergencies can only be analyzed based on the emergency protocols, which are mostly paper-based and handwritten. That causes an increased effort in the evaluation, which makes studies for the whole country hardly feasible. As of now there are only few data on quality of healthcare and documentation by the paramedics. Both were analyzed in this survey based on the emergency protocols.A retrospective analysis of emergency protocols from June to July 2018 took place in Aachen, a major German city. A specific feature of Aachen is a 24‑h available emergency physician via telemedicine. The quality of documentation and healthcare was analyzed by including standard operating procedures. Primary endpoints were the frequency of documentation, the achievement of complete documentation, the correct indications for a physician, the development of critical vital signs and the average on-scene time of the ambulance.Overall, 1935 protocols were analyzed. A complete documentation was achieved in 1323 (68.4%) suspected diagnoses, 456 (23.6%) anamneses, 350 (18.1%) initial and 52 (2.7%) vital signs at handover. Based on the documentation, there were 531 cases (27%) of patients treated by paramedics only, even though a physician would have been indicated. Out of those patients 410 critical initial vital signs were documented of which 69 (16.8%) improved, while there was no documentation of vital signs at handover in 217 (52.9%). Also, there was a significantly prolonged on-scene time for patients with belated indications for an emergency physician with 15:02 min in comparison to 13:05 min for patients without indications.Deficient documentation was found in multiple cases and several important vital signs for a complete differential diagnosis were missing. Furthermore, a quarter of all patients might have benefited from an emergency physician as they were taken to hospital with no or insufficient treatment, despite standard operating procedures. From a forensic point of view there is an alarmingly incomplete documentation of vital signs at handover. The on-scene time in general was within the predetermined time frame, but can still be reduced in different scenarios. Overall, we recommend strict adherence to the standard operating procedures and algorithms, to remove unnecessary documentation and implement a structured quality assurance. Moreover, the quality of treatment might benefit from the rising number of more specialized paramedics and an increasing use of telemedicine.HINTERGRUND: Der deutsche Rettungsdienst wird jährlich zu ca. 7,3 Mio. Einsätzen alarmiert, welche zu einem Großteil (ca. 59 %) ohne Arzt ablaufen. Da kaum Daten zur Qualität der medizinischen Versorgung und Dokumentation von Rettungsdiensteinsätzen ohne Arzt vorliegen, sollen diese anhand der Einsatzprotokolle im Rahmen dieser Studie überprüft werden.Es erfolgte eine retrospektive Analyse von Protokollen der Rettungsdiensteinsätze ohne Arzt aus den Monaten Juni und Juli 2018. Unter Einbezug von Verfahrensanweisungen wurden die Dokumentations- und Behandlungsqualität der Einsätze analysiert. Primäre Endpunkte waren Dokumentationshäufigkeit, Vollständigkeit, die korrekte Notarzt- oder Telenotarztindikationsstellung, die Entwicklung von kritischen Vitalparametern im Einsatzverlauf sowie die mediane Behandlungszeit.Insgesamt wurden 1935 Protokolle ausgewertet. Die Verdachtsdiagnose wurde in 1323 (68,4 %), die Anamnese in 456 (23,6 %), der Erstbefund in 350 (18,1 %) und der Letztbefund in 52 (2,7 %) der Fälle vollständig dokumentiert. Anhand der Dokumentation bestand bei 531 (27 %) Patienten eine Telenotarzt- bzw. Notarztindikation, jedoch kein Arztkontakt. Bei diesen Patienten wurden 410 kritische Vitalparameter im Erstbefund dokumentiert. Von diesen Vitalwerten verbesserten sich 69 (16,8 %); bei 217 (52,9 %) wurde kein Übergabebefund dokumentiert. Die mediane Behandlungsdauer vor Ort war bei Patienten mit eigentlicher Notarztindikation (15:02 min) signifikant länger als bei Patienten ohne Indikation (13:05 min).Die Dokumentation der Einsätze ist defizitär. Zudem könnte ein Viertel der Patienten von einem prähospitalen Arztkontakt profitieren. Eine juristisch bedenkliche Übergabedokumentation besteht bei ca. der Hälfte aller Protokolle.

BackgroundApproximately 100,000 patients suffer from sudden cardiac arrest (CA) annually in Germany. The causes for CA are cardiac in 75% of these cases. The present study aims to investigate the medical prehistory of patients who suffered from out-of-hospital cardiac arrest (OHCA) in a town with 250,000 inhabitants during 5 years and how many of these patients had already been previously treated at the local cardiac arrest center (CAC).Case presentationAll resuscitations due to OHAC were retrospectively analyzed for the cause of OHCA, preexisting cardiac conditions and treatment, lay resuscitation, and outcome from January 1, 2012, to December 31, 2016, in Aachen, Germany. Data analysis was based on the resuscitation protocols and data from the CAC clinical information system. More than 50% of the patients with CA from cardiovascular origin were already known at the receiving respective CAC. Almost 60% of all patients already had cardiac preexisting conditions. Nevertheless, lay resuscitation occurred in only 34.1% of all cases. It was not performed in more than 60% although the probability of discharge can be significantly increased by lay resuscitation.ConclusionThe rate of lay resuscitation is relatively low although many patients suffering from CA have cardiac preexisting conditions. These findings show the importance of better priming their relatives for emergencies to improve lay resuscitation and improve the chances for a better outcome.

Zusammenfassung Hintergrund Das im November 2019 in der Stadt Wuhan entdeckte Coronavirus SARS-CoV-2 ist mittlerweile Ursache einer Pandemie mit weitreichenden Folgen. Dennoch berichten viele Rettungsdienstbereiche von einer Abnahme der Gesamteinsatzzahlen. Methode Im Rahmen einer Kohortenanalyse wurden die Einsatzzahlen von Notarzt- und Telenotarzteinsätzen aus März 2020 mit denen aus den Monaten März 2018 und 2019 hinsichtlich potenziell lebensbedrohlicher Einsätze verglichen. Darüber hinaus wurden alle Einsatzdokumentationen von Rettungswagen, Notarzteinsatzfahrzeug und Telenotarzt der Stadt Aachen aus dem Monat März 2020 ausgewertet. Ergebnisse Im März 2020 kam es im Vergleich zu 2018 und 2019 zu einem signifikanten Rückgang der Notarzteinsätze (p Schlussfolgerung Vor allem die Einsatzzahlen von nicht lebensbedrohlichen Bagatelleinsätzen gingen im März 2020 zurück. Viele Patienten wurden trotz unauffälliger Vitalparameter durch einen Rettungswagen ins Krankenhaus transportiert. Durch eine vermehrte telenotärztliche Begutachtung könnten nicht indikationsgerechte Transporte reduziert werden.

Zunehmender Arztemangel sowie die teilweise durch den demographischen Wandel bedingte steigende Anzahl an Rettungsdiensteinsatzen machen einen bedarfsoptimierten Einsatz der vorhandenen Ressourcen im Rettungsdienst erforderlich. Durch Etablierung eines telemedizinisch verfugbaren Notarztes in Verbindung mit einem holistischen Telemedizinsystem, welches die Ubertragung von Vitaldaten in Echtzeit, 12-Kanal-Elektrokardiogramm (EKG), Sprache, Bildern und Video ermoglicht, kann dieses Ziel erreicht werden. Der Telenotarzt ermoglicht ohne Verletzung des Fernbehandlungsverbots die Verkurzung des arztlich therapiefreien Intervalls sowie eine hochqualifizierte Unterstutzung von nichtarztlichem und arztlichem Personal. Um dies aber auf einem qualitativ hochwertigen Niveau standardisiert zu ermoglichen, ist ein definiertes Anforderungsprofil notwendig. So muss der Telenotarzt uber umfangreiche Erfahrungen, kombiniert mit fundiertem Wissen, auf dem Gebiet der Notfallmedizin verfugen sowie in der Lage sein, checklistenbasiert unter Anwendung bestimmter Fertigkeiten eine leitliniengerechte Patientenversorgung anzuleiten. Die Kommunikation einer Arbeitsdiagnose in kurzester Zeit durch Interpretation einer Ubergabe und situationsabhangig zielfuhrenden Fragen ist erforderlich. Daruber hinaus ist Vertrauen in das Rettungsteam hinsichtlich der Delegation von Masnahmen und Medikamenten notwendig.

Leider haben sich Wiederbelebungstrainings in Deutschlands Schulen trotz nachgewiesener Effektivitat bisher nicht flachendeckend durchgesetzt. Entwicklung eines auf minimale Anforderungen beschrankten, eine Schulstunde dauernden Trainings zum Erlernen der Basic-Life-Support(BLS)-Masnahmen, mit dem die Schulen fur die eigenstandige Durchfuhrung motiviert werden sollen. Allen weiterfuhrenden Schulen in Stadt und Stadte-Region Aachen wurde ein kostenloses Wiederbelebungstraining angeboten. Dieses fand an einem Schultag in der Schule statt, es wurden alle Schuler in Gruppen von bis zu 88 Schulern pro Schulstunde gleichzeitig theoretisch sowie praktisch geschult. Vor und nach dem Training fullten Schuler sowie Lehrer einen Fragebogen aus. Insgesamt konnten in 1,5 Jahren 10.733 Schuler an 25 (40 %) der 62 Schulen in Wiederbelebung trainiert werden. Jeder Schuler fuhrte hierbei mindestens 8 min lang eine Herzdruckmassage durch. 14 % der Schuler gaben vor dem Training an, einen Herzkreislaufstillstand sicher erkennen zu konnen, nach dem Training waren es 63 %. Nach dem Training wussten 91 % der Schuler, was bei einem Kreislaufstillstand zu tun ist, vor dem Training waren es 20 %. Das Training wurde sowohl von den Lehrkraften als auch den Schulern als gut bis sehr gut bewertet. Die Zeit bis zur dringend notwendigen verpflichtenden Einfuhrung von Wiederbelebungstrainings sollte sinnvoll genutzt werden. Die organisatorisch problemlose Durchfuhrung der 45-min-Trainings zeigt, dass die Schwierigkeit der Initiierung eines Wiederbelebungstrainings nicht in der Durchfuhrung selbst, sondern der initialen Uberzeugung der Schule, sich an dieser Masnahme zu beteiligen, liegt.

In 2014, a telemedicine system was established in 24-h routine use in the emergency medical service (EMS) of the city of Aachen. This study tested whether the diagnostic concordance of the tele-EMS physician reaches the same diagnostic concordance as the on-site-EMS physician. The initial prehospital diagnoses were compared to the final hospital diagnoses. Data were recorded retrospectively from the physicians’ protocols as well as from the hospital administration system and compared. Also, all diagnostic misconcordance were analysed and reviewed in terms of logical content by two experts. There were no significant differences between the groups in terms of demographic data, such as age and gender, as well as regarding the hospital length of stay and mortality. There was no significant difference between the diagnostic concordance of the systems, except the diagnosis “epileptic seizure”. Instead, in these cases, “stroke” was the most frequently chosen diagnosis. The diagnostic misconcordance “stroke” is not associated with any risks to patients’ safety. Reasons for diagnostic misconcordance could be the short contact time to the patient during the teleconsultation, the lack of personal examination of the patient by the tele-EMS physician, and reversible symptoms that can mask the correct diagnosis.

BACKGROUND Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident. OBJECTIVE In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device. METHODS A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices. RESULTS A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices. CONCLUSIONS The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non–time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management.

BACKGROUND As a consequence of increasing emergency medical service (EMS) missions requiring an EMS physician on site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany. OBJECTIVE We sought to assess the utilization, safety, and technical performance of this telemedical emergency service. METHODS We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250,000 inhabitants) during the first 3 operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations. RESULTS The data of 6265 patients were analyzed. The number of teleconsultations increased during the run-in period of four quarters toward full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock, and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95% CI 9.1-42.6; P=.009). Only 6 of 6265 patients (0.10%; 95% CI 0.04%-0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95% CI 0.2%-0.5%) during two-way voice communications to as high as 1.9% (95% CI 1.6%-2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95% CI 0.2%-0.6%) of all teleconsultations. CONCLUSIONS The Aachen prehospital EMS is a frequently used, safe, and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Noninferiority of the tele-EMS physician compared with an on-site EMS physician needs to be demonstrated in a randomized trial.

Die telemedizinische Vernetzung zwischen medizinischem Personal und Spezialisten hat sich in der prahospitalen Notfallmedizin – wie auch in anderen medizinischen Bereichen – als vorteilhaft erwiesen. In der Notfallmedizin haben sich telemedizinische Teilkomponenten entwickelt, die fur jeweils einzelne Krankheitsbilder anwendbar sind. Neu hingegen ist ein System, das ein breites notfallmedizinisches Spektrum als erganzendes Strukturelement des existierenden boden- und luftgebundenen Rettungssystems abdecken kann. Es wird dargestellt, warum Telemedizin in der Notfallmedizin notwendig und sinnvoll ist, und die wichtigsten Strukturmerkmale werden erlautert. Ein aus unterschiedlichen Hard- und Softwarekomponenten bestehendes System (Telenotarzt-Arbeitsplatz, Server-Infrastruktur, mobile und im Rettungswagen fest verbaute Ubertragungseinheit) gewahrleistet die Verfugbarkeit medizinischer Daten und den sicheren Datentransfer (Sprache, Echtzeit-Vitalparameter-Kurven und Werte, Fotos, Videostream, 12-Kanal-EKG etc.) in Echtzeit. Basis fur eine sichere Telemedizin sind die Strukturempfehlungen der Deutschen Gesellschaft fur Anasthesiologie und Intensivmedizin. Anwendbar ist die Telemedizin bei unterschiedlichsten Krankheitsbildern und Indikationen. Jedoch unterliegt das System auch Grenzen und Limitationen. Schlussfolgerungen Telemedizin in der prahospitalen Phase ist sicher, erreicht im Vergleich zum konventionellen Notarztsystem eine bessere Dokumentationsqualitat, verkurzt die arztliche Bindungszeit um 50 %, reduziert die Gesamtzahl der arztlich begleiteten Rettungsdiensteinsatze und zeigt eine mindestens gleichwertige medizinische Versorgungsqualitat.

Introduction Telemedical concepts in emergency medical services (EMS) lead to improved process times and patient outcomes, but their technical performance has thus far been insufficient; nevertheless, the concept was transferred into EMS routine care in Aachen, Germany. This study evaluated the system’s technical performance and compared it to a precursor system. Methods The telemedicine system was implemented on seven ambulances and a teleconsultation centre staffed with experienced EMS physicians was established in April 2014. Telemedical applications included mobile vital data, 12-lead, picture transmission and video streaming from inside the ambulances. The tele-EMS physician filled in a questionnaire regarding the technical performance of the applications, background noise and assessed clinical values of the transmitted pictures and videos after each mission between 15 May 2014–15 October 2014. Results Teleconsultation was established during 539 emergency cases. In 83% of the cases ( n = 447), only the paramedics and the tele-EMS physician were involved. Transmission success rates ranged from 98% (audio connection) to 93% (12-lead electrocardiogram (ECG) transmission). All functionalities, except video transmission, were significantly better than the pilot project ( p Discussion The multifunctional system is now sufficient for routine use and is the most reliable mobile emergency telemedicine system compared to other published projects. Dropouts were due to user errors and network coverage problems. These findings enable widespread use of this system in the future, reducing the critical time intervals until medical therapy is started.

Background Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. Methods This was a phase II, multicentre, randomized, double-blind, parallel-group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr-old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon- or sevoflurane-based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). Results Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 -14.9]) or with sevoflurane (13.6% [95% CI: 7.8 -19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least-squares mean difference: −0.33 [95% CI: −0.60 to −0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. Conclusions Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA-scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. Clinical trial registration EudraCT 2009-017153-35; ClinicalTrials.gov NCT01199276.

Aim Demographic changes, decreasing availability of general practitioners, and at least regional shortage of qualified emergency medical service (EMS) physicians led to increasing arrival times and quality problems. Telemedical solutions could help to solve some of the problems. Methods Overall safety and feasibility of prehospital telemedically guided care was already proven in two research projects from 2007 to 2013.1–3 Their results led to implementation of a multifunctional mobile telemedicine system in the city of Aachen, Germany. From 04/2014 to 03/2015 all ambulances were equipped with a telemedicine system connected to a teleconsultation centre staffed with anesthesiologists experienced in emergency care. Audio, real-time vital data, 12-lead-ECG, picture transmission, and video streaming from ambulances was accomplished with encrypted and parallelized transmission using. Mission numbers prior and after implementation were compared to evaluate systematic influence. Results From 04/2014 to 06/2016 overall 4.901 EMS missions were supported and guided telemedically: n=4.151 emergency missions (85%) and n=750 (15%) inter-hospital transfers. Prior to implementation (04/2013–03/2014) 17.305 solely ambulance missions (68.7%) and 7.882 ambulance plus EMS physician unit missions were performed (31.3%). After implementation (04/2015–03/2016) 20.102 ambulance missions (76%) and 6.360 ambulance plus EMS physician missions (24%) were conducted which revealed a significant difference between both phases, p Conclusion The implementation of a telemedicine system into routine care led to a significant decrease in conventional on-scene physician missions as well as to an overall decrease in physician guided EMS cases. Therefore, the approach can be judged resource optimising and holds a potential for economic improvements although highly qualified physicians carry out the service. References Brokmann JC, Conrad C, Rossaint R, Bergrath S, Beckers SK, Tamm M, Czaplik M, Hirsch F. Treatment of acute coronary syndrome by telemedically supported paramedics compared with physician-based treatment of acute coronary syndrome: a prospective, interventional, multicentre trial. J Med Internet Res2016;18(12):e314doi:10.2196/jmir.6358 Felzen F, Brokmann JC, Beckers SK, Hirsch H, Tamm M, Rossaint R, Bergrath S. Technical performance of a multifunctional prehospital telemedicine system in routine emergency medical care – an observational study. Journal of Telemedicine and Telecare2016; pii: 1357633X16644115. Bergrath S, Reich A, Rossaint R, Rortgen R, Gerber J, Fischermann H, Beckers SK, Brokmann JC, Schulz JB, Leber C, Fitzner C, Skorning M. Feasibility of Prehospital Teleconsultation in Acute Stroke – a pilot study in clinical routine. PLoS ONE2012;7(5):e36796. Conflict of interest None declared. Funding None declared.

Methylphenidate (MPH) inhibits the reuptake of dopamine and noradrenaline. PET studies with MPH challenge show increased competition at postsynaptic D2/3-receptors, thus indirectly revealing presynaptic dopamine release. We used [18F]fluorodopamine ([18F]FDOPA)-PET in conjunction with the inlet–outlet model (IOM) of Kumakura et al. (2007) to investigate acute and long-term changes in dopamine synthesis capacity and turnover in nigrostriatal fibers of healthy subjects with MPH challenge. Twenty healthy human females underwent two dynamic [18F]FDOPA PET scans (124 min; slow bolus-injection; arterial blood sampling), with one scan in untreated baseline condition and the other after MPH administration (0.5 mg/kg, p.o.), in randomized order. Subjects underwent cognitive testing at each PET session. Time activity curves were obtained for ventral putamen and caudate and were analyzed according to the IOM to obtain the regional net-uptake of [18F]FDOPA (K; dopamine synthesis capacity) as well as the [18F]fluorodopamine washout rate (kloss, index of dopamine turnover). MPH substantially decreasedklossin putamen (−22%;p= 0.003). In the reversed treatment order group (MPH/no drug),Kwas increased by 18% at no drug follow-up. The magnitude ofKat the no drug baseline correlated with cognitive parameters. Furthermore, individualklosschanges correlated with altered cognitive performance under MPH. [18F]FDOPA PET in combination with the IOM detects an MPH-evoked decrease in striatal dopamine turnover, in accordance with the known acute pharmacodynamics of MPH. Furthermore, the scan-ordering effect onKsuggested that a single MPH challenge persistently increased striatal dopamine synthesis capacity. Attenuation of dopamine turnover by MPH is linked to enhanced cognitive performance in healthy females.

We evaluated the technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service (EMS) from the user's perspective. The telemedicine system was designed to transmit vital signs data and 12-lead-ECG data, send still pictures and allow voice communication and video transmission from an ambulance. The data were sent to a teleconsultation centre staffed with EMS physicians (tele-EMS physician). The system was used in 157 EMS missions. The applications were used successfully on 80% of missions for real-time vital signs transmission and on 97% for video transmission. The quality of the transmitted still images ( n = 64) was: 23% excellent, 50% good, 17% moderate, 9% rather poor and 0% unusable. The quality of the video streaming ( n = 36) was: 33% excellent, 56% good, 6% moderate, 6% rather poor and 0% unusable. The tele-EMS physician was able to assist the EMS team in several cases and provided the preliminary information for the hospital in nearly all missions. Use of the telemedical system in EMS is feasible and the quality of the transmitted images and video was satisfactory. However, technical reliability and availability need to be improved prior to routine use.