The COVID-19 pandemic and follow-up for shoulder surgery: The impact of a shift toward telemedicine on validated patient-reported outcomes.

INTRODUCTION: The emergence of COVID-19 and its ensuing restrictions on in-person healthcare has resulted in a sudden shift towards the utilization of telemedicine. The purpose of this study is to assess patient satisfaction and patient-reported outcome measures (PROMs) for individuals who underwent follow-up for shoulder surgery using telemedicine compared to those who received traditional in-person clinic follow-up. METHODS: Patients who underwent either rotator cuff repair or total shoulder arthroplasty during a designated pre-COVID-19 (traditional clinic follow-up) or peri-COVID-19 (telemedicine follow-up) span of time were identified. PROMs including the American Shoulder and Elbow Surgeons standardized assessment form, the three-level version of the EQ-5D form, the 12-Item Short Form survey, and a modified version of a published telemedicine survey were administered to participants six months post-operatively via phone call. RESULTS: Sixty patients agreed to participate. There was no significant difference between the pre-COVID-19 and peri-COVID-19 groups in patient satisfaction with their follow-up visit (p = 0.289), nor was there a significant difference in PROMs between the two groups. In total, 83.33% of the telemedicine group and 70.37% of the in-person clinic group preferred traditional in-person follow-up over telemedicine. DISCUSSION: In a cohort of patients who underwent telemedicine follow-up for shoulder surgery during the COVID-19 pandemic, there was no difference in patient satisfaction and PROMs compared to traditional in-person clinic follow-up. This study indicates that while the majority of participants preferred face-to-face visits, patients were relatively satisfied with their care and had similar functional outcome scores in both groups, despite the large disruption in healthcare logistics caused by COVID-19.

Impact of the COVID-19 pandemic on patients with osteogenesis imperfecta

OBJECTIVES: On March 11, 2020, the WHO classified COVID-19 as a global pandemic. Measures to quell the pandemic included limiting non-essential activities including clinic visits and procedures. It is unclear if individuals with OI had disruptions in their access to healthcare or medications, and if such disruptions affected patients' symptoms. METHOD(S): A REDCap survey was distributed through the OI Foundation on August 31. Surveys completed through September 11 by individuals with OI or their caregiver are included in this analysis. Participants were asked to compare their symptoms and access to healthcare during the first 4 months of the pandemic to the 4 months before the pandemic. RESULT(S): 85 surveys were completed, and 6 were partially completed. The median age of participants was 40 years;35% were children. 32% of participants self-identified as having severe OI. Although most reported no changes in bone pain or fractures, 46% reported they were less likely to seek emergency medical care to treat a fracture, while 33% reported they were more likely to treat fractures at home (Fig 1A). There were delays in accessing all services, with greatest delays accessing dentistry (74%) and aquatic therapy (84%) (Fig 1B). 36% of participants receiving bisphosphonate infusions had delayed infusions because of the pandemic (Fig 1C). Of note, 50% of planned surgeries were delayed. CONCLUSION(S): Although many individuals with OI and their caregivers reported delays in accessing bone-related services/clinics during this 4-month period, there was not a concomitant increase in reported symptoms. This may have related to shelter-in-place restrictions and decreased activity. Limitations of this study include small sample size and potential selection bias because responses were obtained only from OIF members. To address these limitations, we are distributing the survey through healthcare providers of individuals with OI across major regions of the US from a variety of practice types including endocrine, orthopedics and multidisciplinary clinics. Furthermore, as the COVID-19 pandemic continues, we hope that this survey will provide information to address what aspects of healthcare may be in greatest need, as well as the modality through which services may be met. (Figure Presented).

News in paediatric orthopaedic surgery: an overview of the latest advances in paediatric orthopaedics and traumatology (2020-2023).

PURPOSE: We propose to survey - even if arbitrarily - the publications in paediatric orthopaedics and traumatology that have had the greatest impact on the specialty during the period extending from the beginning of the COVID-19 pandemic in December 2020 and the end of all health restrictions in March 2023. METHODS: Only studies with a high level of evidence or clinical relevance were selected. We briefly discussed the results and conclusions of these quality articles to situate them in relation to the existing literature and current practice. RESULTS: Publications are presented by dividing traumatology and orthopaedics whose publications are further subdivided according to anatomical districts; articles concerning neuro-orthopaedics, tumours, and infections were presented separately while sports medicine is jointly presented with knee-related articles. CONCLUSIONS: Despite the difficulties encountered during the global COVID-19 pandemic (2020-2023), orthopaedic and trauma specialists, including paediatric orthopaedic surgeons, have maintained a high level of scientific output, in terms of quantity and quality of production.

International Residents' Perspectives on Education and Challenges in Microsurgery Training

Objective Microsurgery remains an integral component of the surgical skillset and is essential for a diversity of reconstructive procedures. The apprenticeship also requires overcoming a steep learning curve, among many challenges. The method of microsurgical training differs depending on the countries' regions and resources of their health care system. Methods The Journal of Hand and Microsurgery leadership held an international webinar on June 19, 2021, consisting of a panel of residents from 10 countries and moderated by eminent panelists. This inaugural event aimed to share different experiences of microsurgery training on a global scale, identifying challenges to accessing and delivering training. Results Residents shared various structures and modes of microsurgical education worldwide. Areas of discussion also included microsurgical laboratory training, simulation training, knowledge sharing, burnout among trainees, and challenges for female residents in microsurgical training. Conclusion Microsurgical proficiency is attained through deliberate and continued practice, and there is a strong emphasis globally on training and guidance. However, much remains to be done to improve microsurgical training and start acting on the various challenges raised by residents.Copyright © 2022. Society of Indian Hand & Microsurgeons. All rights reserved.

Is COVID-19 a risk for postoperative delirium and death in elderly patients after emergency surgery?

Aim: While recent evidence describes atypical outcomes of coronavirus disease 2019 (COVID-19) in elderly patients, the frequency of delirium and associated outcomes in elderly patients with COVID-19 (coronavirus disease 2019) infection undergoing emergency surgery are not well defined. This study aims to determine the effect of COVID-19 on postoperative delirium and postoperative death in elderly patients undergoing emergency surgery. Material(s) and Method(s): This descriptive and cross-sectional study was conducted in general surgery, orthopedics, and cardiovascular surgery clinics of a public hospital, including 30 days of follow-up between April 1 and May 1, 2021. All patients who were admitted to these clinics for emergency surgery intervention on these dates constituted the study population, while a total of 140 patients aged >=65 years, who met the study criteria, formed the sample of the study. Descriptive Characteristics Form and Nursing Delirium Screening Scale (Nu-DESC) were used as data collection tools in the study. SPSS 25.0 statistical program was used for data analysis. Result(s): Thirty (42.85%) of the SARS-CoV-2 positive (n=70) patients developed delirium in the study. 12.9% (n=18) of the patients died within 30 days of follow-up after surgery. There were 30 (69.8) of 70 SARS-CoV-2 positive patients who developed delirium, and 12 patients (25.5) died after testing positive for COVID-19, with a mean of 8.08T1.56 days within 30 days of admission. Discussion(s): These findings may lead to a poor clinical prognosis for COVID-19 infection delirium and postoperative death in patients over 65 years of age undergoing emergency surgery.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Telehealth in Orthopedic Sports Medicine: A Survey Study on Patient Satisfaction and Experience.

Background: Telehealth has seen breakthroughs in many fields of medicine, but utilization remains limited in orthopedic sports medicine. The purpose of this investigation was to compare patient satisfaction, duration of care, and overall patient experiences with telehealth and in-person clinical visits for sports-related injuries. Methods: A cross-sectional survey study was conducted at an orthopedic sports medicine clinic during the peak of the COVID-19 pandemic between March and November 2020. Anonymous electronic surveys were used to record patient responses and statistical comparisons were drawn through two-sample t-tests. Results: A total of 175 patients (82 telehealth vs. 93 in-person) consented to participate in this investigation, and all were included in the final analysis. The overall composite satisfaction score, when compared between the two groups, did not differ (p = 0.63). Duration of care was significantly longer in the 93 patients who had in-person clinical visits as compared with the 82 patients who had telehealth visits (61/93: >31 min vs. 75/82: <30 min; p < 0.001). Finally, of the 82 patients who had telehealth, 3 respondents said they were "very unlikely" and "unlikely" to request another virtual clinical visit and/or recommend this mode of health care delivery to friends or family. Of the 93 patients had in-person clinical visits, only 15 respondents stated they were uninterested in telehealth under any circumstance. Conclusion: Most patients presenting to an orthopedic sports medicine clinic are open to telehealth, recognize its utility, and believe it to be just as comparable with in-person clinical visits. Level of Evidence: IV.

Comparison of Survivorship and Failure Modes Between Anatomic and Reverse Total Shoulder Arthroplasty Across Multiple Government Joint Registries for a Single Platform Shoulder System

[...]recent years have seen a dramatic shift in utilization of rTSA in which rTSA is increasingly used to treat OA in patients with an intact rotator cuff, with a corresponding decline in use of aTSA.1-5 The reasons for this shift in usage are multi-factorial but may be due to the perceived lower risk of revision surgery with rTSA relative to aTSA, as the quality of the rotator cuff muscles and tendon are not necessary for a functional rTSA but are pre-requisite for a functional aTSA. Furthermore, these registries have high rates of government-mandated compliance such that all patients are enrolled and very few patients are lost to follow-up, thus minimizing the potential for selection bias that is inherently present in nearly all nongovernment registry clinical outcome studies. [...]to better understand the relative differences in primary aTSA and primary rTSA usage and performance, we analyzed two different government joint registries for survivorship and for reasons for revision associated with one platform shoulder system and compared trends in usage of aTSA and rTSA over a period of over 10 years to elucidate reasons for any market trends. Additionally, reasons for revision and the cumulative revision rate were assessed across the government joint registries to quantify and compare the performance of this platform shoulder prosthesis for primary aTSA and primary rTSA in each country over the study period. Over the period of analysis, use of primary aTSA and primary rTSA with the particular platform system has increased year to year in both Australia and the UK, with the exception of a decline in 2020 and 2021 due to COVID-19.

The impact of the COVID-19 associated shutdown on orthopedic patient care.

BACKGROUND: Due to the surge of COVID-19 cases in the US in early March 2020, health care facilities temporarily suspended elective and non-urgent medical procedures such as joint replacement surgeries. The aim of this study was to analyze the impact of the COVID-19 associated shutdown on orthopedic patient care at a specialized orthopedic hospital located at the epicenter of the COVID-19 pandemic. METHODS: Patient volume of outpatient visits and joint replacement surgeries were analyzed and compared for 2019 and 2020. The volumes were further aligned with the timeline of governmental and institutional COVID-19 associated restrictions. RESULTS: The annual surgery volume was reduced by 20.2% in 2020 and did not make up for the reduction experienced during the shutdown. The total number of patient visits decreased by 25.5% and new patient visits remained 25% lower at the end of 2020. Patient care and surgery volume recovered with declining SARS-CoV-2-cases but did not return to levels prior to the shutdown. During the second quarter of 2020, 28.5% of all patient visits were telehealth appointments. By the end of the year it dropped to 7.6%. There was a shift towards patient appointments at outpatient satellite offices. CONCLUSION: Orthopedic providers faced a substantial disruption in outpatient and surgical volume. Telemedicine appointments were crucial for maintaining follow-up patient care and will be an important sector in future patient care. There has been a major push to utilize satellite offices outside the city center.

Outcome Of Non-Elective Covid Positive Orthopaedic Injury Procedures In Two Tertiary Care Hospitals

Objective: To evaluate the outcome of COVID-positive orthopaedic injury patients operated as emergency cases regarding overall disease progression, laboratory parameters and fracture healing. Study Design: Prospective longitudinal study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi and Combined Military Hospital Malir Karachi Pakistan, from Apr to Nov 2020. Methodology: All the orthopaedic injury patients with no other injuries who tested positive for COVID-19 were included in the study. The demographic data, time of injury and surgery, co-morbidities and values of inflammatory markers such as Creactive protein (CRP), Total Leukocyte Count (TLC), Serum Ferritin and Neutrophil percentage were noted pre-op and on the fifth-day post-operation. The bone fracture, its severity, and the type of orthopaedic intervention were also noted. Results: A total of 17 patients were included in the study, out of which 12 were males (70.6%), and 5 were females (29.4%), with a mean age of 49.06±18.78 years. There were 9(52.9%) cases of mild COVID-19, 3(17.6%) cases of moderate and 5(29.2%) cases of severe disease among orthopaedic injury cases. The most common fracture was of the femur in 12(70.6%) patients, followed by tibia/fibula in 3(17.6%) and 2(11.8%) cases of radius and ulna. In addition, there were 2(11.8%) cases of non-union and 5(29.4%) delayed union. Only 2(5.2%) health professionals developed mild COVID. Conclusion: Orthopedic emergency operations of COVID-19-positive patients can be performed safely following strict COVID-19 protocols.

Enhance-Net: An Approach to Boost the Performance of Deep Learning Model Based on Real-Time Medical Images

Real-time medical image classification is a complex problem in the world. Using IoT technology in medical applications assures that the healthcare sectors improve the quality of treatment while lowering costs via automation and resource optimization. Deep learning is critical in categorizing medical images, which is accomplished by artificial intelligence. Deep learning algorithms allow radiologists and orthopaedic surgeons to make their life easier by providing them with quicker and more accurate findings in real time. Despite this, the classic deep learning technique has hit its performance limits. For these reasons, in this research, we examine alternative enhancement strategies to raise the performance of deep neural networks to provide an optimal solution known as Enhance-Net. It is possible to classify the experiment into six distinct stages. Champion-Net was chosen as a deep learning model from a pool of benchmark deep learning models (EfficientNet: B0, MobileNet, ResNet-18, and VGG-19). This stage helps choose the optimal model. In the second step, Champion-Net was tested with various resolutions. This stage helps conclude dataset resolution and improves Champion-Net performance. The next stage extracts green channel data. In the fourth step, Champion-Net combines with image enhancement algorithms CLAHE, HEF, and UM. This phase serves to improve Enhance-performance. The next stage compares the Enhance-Net findings to the lightness order error (LoE). In Enhance-Net models, the current study combines image enhancement and green channel with Champion-Net. In the final step, radiologists and orthopaedic surgeons use the trained model for real-time medical image prediction. The study effort uses the musculoskeletal radiograph-bone classification (MURA-BC) dataset. Classification accuracy of Enhance-Net was determined for the train and test datasets. These models obtained 98.02 percent, 94.79 percent, and 94.61 percent accuracy, respectively. The 96.74% accuracy was achieved during real-time testing with the unseen dataset.

Exploration of Immersive Virtual Reality in Teaching Veterinary Orthopedics.

The COVID-19 pandemic has catalyzed the use of novel teaching modalities to enhance the provision of remote veterinary education. In this study, we describe the use of immersive virtual reality (iVR) as a teaching aid for veterinary medicine students during their orthopedics clinical rotation. Student sentiments were assessed using voluntary electronic surveys taken by veterinary students before and after the rotation. The most noteworthy benefits students reported were improved engagement with the course content, information retention, radiographic interpretation, and clinical reasoning skills. Obstacles encountered during the initial stages of the program included financial and temporal investment in equipment and content development, technical troubleshooting, and motion sickness. Though it is unlikely that iVR will ever fully replace hands-on learning experiences, it presents an educational opportunity to supplement traditional learning methods, motivate students, and fill information gaps. As iVR technology continues to evolve and improve, potential applications in the veterinary curriculum grow, making the modality's use progressively more advantageous. Although this study describes its application in an orthopedic setting, the versatility of the iVR modality lends the potential for it to be implemented in a number of clinical and didactic settings.

Telemedicine Orthopedic Consultations Duration and Timing in Outpatient Clinical Practice During the COVID-19 Pandemic.

Introduction: Orthopedic associations advocated telemedicine during the COVID-19 pandemic to prevent disease transmission without hindering providing services to orthopedic patients. The study aimed to evaluate outpatient orthopedic teleconsultations' timing, length, and organizational issues in the circumstances of the COVID-19 pandemic based on consecutive orthopedic teleconsultations during the period of the first lockdown. Methods: Orthopedic telemedical consultations (OTCs) were provided from March 23, 2020, to June 1, 2020, and analyzed retrospectively based on mobile smartphone billing and electronic health record. Teleconsultations were based on the legal regulations of telemedicine services in Poland. Results: One thousand seventy-one patients (514 women and 557 men) with a mean age of 41.7 were teleconsulted. The length of the OTC averagely lasted 13.36 min (standard deviation 8.63). Consulted patients suffered from orthopedic disorders 65.3%, musculoskeletal injuries 26.3%, and other diseases 8.4%. Most OTCs were delayed (74.22%) concerning the planned schedule, with a median delay time of 12 min. Only 7.3% of teleconsultations were held precisely on time. Conclusions: Televisit length may not be dependent on gender, older age, or more diagnoses. The services like e-prescriptions, e-Referrals, e-Orders for orthotics, and e-Sick-leaves influence OTC length. Any extension of the patient's OTC may create a "snowball effect" of further delay for each subsequent OTC. Orthopedic teleconsultation requires new understanding and skills by both the patient and specialist physicians. Future research directions should concern the practical aspects of orthopedic teleconsultations, like legal, organizational, and technological issues and their implementation.

E-scooter use continues to rev up fracture diagnoses and hospital admissions compared to other modes of transportation.

Introduction: The COVID-19 pandemic was associated with an increase in popularity of e-scooter usage and a rise in e-scooter related injuries. Recent studies have elucidated trends within e-scooter injuries but there are few epidemiological studies that evaluate injury rates amongst multiple modes of transportation. This study seeks to investigate trends of e-scooter orthopedic fracture injuries compared to other traditional methods of transportation using a national database. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried between 2014 and 2020 for patients who were injured after usage of e-scooters, bicycles, or all-terrain vehicles. Primary analysis included patients with a diagnosis of fracture and utilized univariate/multivariate models to evaluate risk of hospital admission. Secondary analysis included all isolated patients to evaluate the odds of fracture development amongst modes of transportation. Results: A total of 70,719 patients with injuries associated with e-scooter, bicycle, or all-terrain vehicle use were isolated. 15997 (22.6%) of these patients had a fracture diagnosis. Both e-scooters and all-terrain vehicles reported increased odds of fracture-related injury and direct hospitalization when compared to bicycles. E-scooter users reported a greater odds of both associated fracture (OR 1.25; 95%CI 1.03-1.51; p = 0.024) and hospital admission (OR: 2.01; 95%CI: 1.26-3.21; p = 0.003) in 2020 compared to 2014-2015. Discussion: E-scooter related orthopedic injuries and hospital admissions had the largest incidence rate increase compared to bicycle and all-terrain vehicles between 2014 and 2020. E-scooter fractures were most commonly located in the lower leg in 2014-2017, the wrist in 2018-2019, and the upper trunk in 2020. In comparison, bicycle and all-terrain vehicle fractures was most commonly shoulder and upper trunk within the study period. Further research will help to promote further understanding of the e-scooter health care burden and in prevention of these injuries. Level of evidence: 3.

Potential Impact of Hospital at Home on Postoperative Readmissions

The first HAH programs in the United States were developed at Johns Hopkins Hospital in the late 1990s and were initially targeted toward geriatric patients with chronic medical problems.2 Follow-up studies focused on medical patients have been performed in multiple patient populations and health systems.3-9 These studies have demonstrated that for medically ill patients, admission to HAH offers significant benefits compared with inpatient admission, including fewer iatrogenic complications such as delirium, improved patient and caregiver satisfaction, decreased readmission rates, and, in some studies, decreased mortality. [...]diverting postoperative readmissions to at-home care has the unique benefit of freeing surgical beds, which can increase procedural capacity and therefore surgical access and hospital revenue. [...]we estimated the margin from new inpatient capacity that could be generated if the hospital avoided HAH-eligible readmissions and backfilled these beds with new medical-surgical admissions. [...]we estimated the potential financial impact on hospital margin of diverting surgical readmissions to an HAH program.

Reactive Arthritis

Reactive arthritis develops as a sequela of a remote infection, usually of the gastrointestinal or genitourinary tract. The presence of acute arthritis and absence of specific diagnostic test markers can lead to misdiagnosis. Prompt recognition and proper management prevent reactive arthritis from progressing to a chronic destructive arthritis. The nurse practitioner's familiarity with reactive arthritis, signs and symptoms, diagnostic criteria, and treatment regimen promote early intervention for achieving the best outcomes, including remission.

Shoulder Pseudo-Tumor from COVID-19 Vaccine.

Hypersensitivity reactions to the COVID-19 mRNA vaccines were identified in the initial 2020 trials. Appearance of a soft tissue mass is a rare manifestation of this hypersensitivity reaction. In this patient, bilateral injections resulted in the appearance of shoulder masses. Magnetic resonance imaging showed localized pseudo-tumorous edema in both shoulders, one subcutaneous and the other intramuscular. This is only the second case of a mass-like reaction to the COVID-19 vaccine mimicking a possible soft tissue neoplasm. Improper vaccination administration technique may have contributed to this complication. The case is presented to increase awareness of this potential pseudotumor.

A comparative study looking at trauma and orthopaedic operating efficiency in the COVID-19 era.

BACKGROUD: COVID-19 has led to a reduction in operating efficiency. We aim to identify these inefficiencies and possible solutions as we begin to pursue a move to planned surgical care. METHODS: All trauma and orthopaedic emergency surgery were analysed for May 2019 and May 2020. Timing data was collated to look at the following: anaesthetic preparation time, anaesthetic time, surgical preparation time, surgical time, transfer to recovery time and turnaround time. Data for 2019 was collected retrospectively and data for 2020 was collected prospectively. RESULTS: A total of 222 patients underwent emergency orthopaedic surgery in May 2019 and 161 in May 2020. A statistically significant increase in all timings was demonstrated in 2020 apart from anaesthetic time which demonstrated a significant decrease. A subgroup analysis for hip fractures demonstrated a similar result. No increase in surgical time was observed in hand and wrist surgery or for debridement and washouts.Although the decrease in anaesthetic time is difficult to explain, this could be attributed to a reduction in combined anaesthetic techniques and possibly the effect of fear. The other increases in time demonstrated can largely be attributed to the PPE required for aerosol generating procedures and other measures taken to reduce spread of the virus. These procedures currently form a large amount of the orthopaedic case load. CONCLUSION: COVID-19 has led to significant reductions in operating room efficiency. This will have significant impact on waiting times. Increasing frequency of regional anaesthesia concurrently with non-aerosol generating surgeries may improve efficiency.

Retour d'expérience sur les transports Smur des patients Covid-19

Dès la fin du mois de février 2020, les urgentistes français ont été confrontés à une situation inédite et complexe dans la gestion des cas les plus sévères d'infections pulmonaires associées au nouveau coronavirus (SARSCoV- 2). Les informations en provenance de Chine et les recommandations initiales de l'Organisation mondiale de la santé ont rapidement amené à considérer l'intubation et la ventilation mécanique précoce des malades atteints par la pneumonie de la Covid-19. Or, dès la fin du mois de mars 2020, grâce aux retours d'expérience et de prise en charge, d'abord de la part des réanimateurs et urgentistes italiens, puis espagnols, les pratiques et les recommandations concernant les modalités d'oxygénation et de ventilation des patients Covid-19 ont évolué. Le caractère exceptionnel de cette pandémie et la grande adaptabilité des services de Samu/Smur de France, en l'espace de quelques semaines, pour prendre en charge ces patients oxygénodépendants, justifient que nous en fassions le retour d'expérience, et ce, d'autant plus que nous sommes exposés à un risque de recrudescence d'infections respiratoires graves associées au SARS-CoV-2 à court terme, risquant de saturer une nouvelle fois notre système de santé. Nous détaillons donc ici le retour d'expérience des prises en charge médicales préhospitalières concernant principalement les supports d'oxygénation et de ventilation mécanique.Alternate abstract: At the end of February 2020, French emergency physicians were faced with a new and complex situation in the management of critical cases of SARS-CoV-2 infection. First information from China and the initial recommendations of the World Health Organization (WHO) quickly led us to consider early intubation and mechanical ventilation of patients with hypoxemic COVID-19 pneumonia. However, since the end of March 2020, feedback from Italian intensive care and emergency physicians, then Spanish, led to change in clinical practices and guidelines about oxygenation and mechanical or noninvasive ventilation of COVID-19 patients have evolved. The exceptional character of this pandemic and the great adaptability of French pre-hospital emergency medical services (Samu/Smur) in a few weeks, to manage those oxygen dependent patients, justified our feedback, especially because we are exposed to a risk of resurgence of serious short-term SARS-CoV-2-associated acute respiratory distress syndrome (ARDS), which could once again saturate our health system. We therefore detail here the feedback of pre-hospital medical care, mainly concerning the management of oxygenation and ventilation supports.