Delayed dorsal scapular artery hematoma following blunt thoracic trauma: a case report and review of the literature.

BACKGROUND: The present case contributes to the limited literature on delayed chest wall hematomas following blunt trauma. The literature review provides a summary of similar previously reported cases. CASE PRESENTATION: We report the case of a 59-year-old Caucasian male who presented to the emergency department with a rapidly expanding chest wall hematoma. Six weeks earlier, he had sustained multiple rib fractures and a pneumothorax after falling 4 m from a ladder. Computed tomography angiography was used to identify two sources of active bleeding on the left dorsal scapular artery. The patient underwent surgery with evacuation of the hematoma and ligation of the artery. The patient was hospitalized for 3 days and recovered with no sequelae. CONCLUSIONS: A literature review revealed eight previously reported cases of chest wall hematomas exterior to the endothoracic fascia following blunt trauma. Most cases were initially diagnosed by computed tomography of the chest and finally by angiogram. Management options range from surgical drainage to angiographic embolization. This case is unusual regarding the delay in the development of the hematoma and illustrates the importance of considering this diagnosis even weeks after relevant trauma.

Barriers and facilitators among health care professionals in the Emergency Department for treating paediatric patients pain and anxiety. A qualitative survey study.

OBJECTIVE: Pediatric patient's pain and anxiety are insufficiently treated in Emergency Departments (EDs). Implementation of new evidence-based knowledge into paediatric clinical practice is often a protracted process, as the barriers and facilitators among health care professionals for treating pain and anxiety in children are unknown. METHOD: We conducted hypothesis generating interviews with health care professionals and coded the transcriptions into eight main themes. A survey was constructed to test the hypotheses, with one question for each theme. The survey was distributed in two EDs. RESULTS: Barriers: fear of overdose (58.9%) lack of knowledge in different treatment options (56.7%), children or parents cannot cooperate (55%). Facilitators: more education (69.4%), more time to treat every patient (55.2%), standardized treatment regime (50%). CONCLUSION: Our study finds potential barriers and facilitators among health care professionals regarding sufficient treatments of pain and anxiety among paediatric patients in EDs. It suggests that education of health care professionals regarding assessing pain, administrating analgesics and anxiolytics and handling uncooperative children is necessary in order to improve treatment of children in EDs.

Nationwide study on trends in unplanned hospital attendance and deaths during the 7 weeks after the onset of the COVID-19 pandemic in Denmark.

BACKGROUND: The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued. METHODS: We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs). RESULTS: From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two. CONCLUSION: The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns.

Interhospital Transport of Pediatric Patients in Denmark: A Survey of Current Practice.

OBJECTIVES: No national guidelines exist in Denmark regarding interhospital transport of critically ill children. The aim of this study was to disclose which physicians actually accompany critically ill children during interhospital transports nationwide and whether the physicians have adequate clinical skills to perform interhospital transfers. METHODS: A questionnaire was sent to the youngest pediatrician on-call at every hospital in Denmark receiving pediatric emergencies except the tertiary Copenhagen University Hospital, Rigshospitalet. RESULTS: Seventeen pediatric departments were contacted (response rate, 100%). All departments indicated that they perform interhospital transport of pediatric patients. When presented with 5 cases, great heterogeneity in the choice of transport physician and accompanying staff was seen. With increasing severity, fewer pediatricians were willing to transport the children (24% vs 6%). Irrespective of the degree of severity, more transports were delegated to anesthesiologists than performed by pediatricians. Pediatricians who agreed to transport the infant and neonate had adequate competencies. In cases with older children, 0 to 75% of physicians who would do the transport had adequate clinical skills and experience in emergency pediatric respiratory and cardiovascular management. Training in interhospital transport was offered by 1 department; 6 departments (35%) had local guidelines describing the management of pediatric transports. CONCLUSIONS: Great heterogeneity was found in the local transport strategies and practical skill sets of accompanying physicians. Overall, there is room for improvement in the management of interhospital transport of critically ill children in Denmark, perhaps by increasing the availability of specialized pediatric transport services for critically ill children nationwide.

Using the Natural Experiment Study Design to Evaluate the Effect of a Change in Doctor's Roster on Patient Flow in an Emergency Department.

INTRODUCTION: The effect of changes in doctors' rosters is rarely subjected to scientific evaluation. We describe how a natural experiment (NE) study design can be used to evaluate if a managerial decision about doctors' rosters has an effect on patient flow in an emergency department (ED). We hypothesized that an extra doctor each morning from 6 a.m. (i.e., a modified "casino shift") might improve the productivity of a hospital's ED. METHODS: This was an NE observational study using data on patient flow in the ED of Zealand University Hospital, Denmark, between April 1, 2016, and April 1, 2017. We compared days on which the 6 a.m. emergency physician called in sick (case days) with data from the same weekday a week later where staffing was as scheduled (control days). RESULTS: Patient caseload did not did differ significantly on days with and without the extra doctor from 6 a.m. (measured by number of admissions, triage scores and mean patient age). Door-to-doctor time was 70 minutes (mean, standard deviation [SD], 49) on days without the extra doctor and 56 minutes (mean, SD 41) on days with the early-morning doctor present (p > 0.05). ED length of stay was 250 minutes (mean, SD 119) on days without the extra doctor and 209 minutes (mean, SD 109) on days with the early-morning doctor present (p > 0.05). CONCLUSION: In our setting, an extra doctor in the ED from 6 a.m. did not change patient flow. These results suggest that the workflow in the ED should be viewed as a connected supply chain. The study also demonstrates that a natural experiment study design can be used to evaluate ED managerial decisions.

Sensemaking in the formation of basic life support teams - a proof-of-concept, qualitative study of simulated in-hospital cardiac arrests.

BACKGROUND: The formation of critical care teams is a complex process where team members need to get a shared understanding of a serious situation. No previous studies have focused on how this shared understanding is achieved during the formation of cardiac arrest teams. "Sensemaking" is a concept well known in organizational studies. It refers to the collaborative effort among members in a dialogue to create meaning in an ambiguous situation, often by using subtle variations in the sentences in the dialogue. Sentences with high degrees of "sensemaking" activity can be thematized as "co-orientation", "re-presentation" and/or "subordination" (among others). We sought to establish if elements of "sensemaking" occur in the formation of in-hospital cardiac arrest teams. METHODS: Videos of ten simulations of unannounced in-hospital cardiac arrests treated by basic life support (BLS) providers. We transcribed all verbal communication from the moment the first responder stepped into the room until the moment external chest compression were initiated (verbatim transcription). Transcriptions were then analyzed with a focus on identifying three elements of sensemaking: Co-orientation, Re-presentation and Sub-ordination. RESULTS: Sensemaking elements could be identified in seven of ten scenarios as part of team formation. Co-orientation was the element that was used most consistently, occurring in all of the eight scenarios that included sensemaking efforts. CONCLUSIONS: Sensemaking is an element in the communication in some cardiac arrest teams. It is possible that the active moderation of sensemaking should be considered a non-technical skill in cardiac arrest teams.

Measurement of respiratory rate by multiple raters in a clinical setting is unreliable: A cross-sectional simulation study.

OBJECTIVE: To evaluate the inter-observer reliability of nurses assessing respiratory rate. METHODS: We presented seven minimum 60-seconds long videos of thoraces of non-identifiable patients breathing to experienced nurses from several Danish emergency departments. Two videos were assessed by 50 raters while five were reviewed by eight. The videos were shown using an online system that also recorded the counted respiratory rate. RESULTS: A total of 140 nurses participated with a median of 15years' experience. The range of counted respiratory rate was minimum 10 on each video. For videos evaluated by eight nurses, average Inter Class Coefficient (ICC) was 0.662 (0.000-0.960) and individual ICC 0.197 (0.000-0.750). For the two case-videos analyzed by 50 nurses, average ICC was 0.0 (0.000-0.991) and individual ICC 0.0 (0.000-0.677). CONCLUSIONS: We found a wide variation in measurements of RR with both few and many observers assessing exactly the same patients.

Using scores to identify patients at risk of short term mortality at arrival to the acute medical unit: A validation study of six existing scores.

INTRODUCTION: "Early warning scores" (EWS) have been developed to quantify levels of vital sign abnormality. However, many scores have not been validated. The aim of this study was to validate six scores that all rely on vital signs: Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS) and the National Early Warning Score (NEWS) and the Goodacre, Groarke and Worthing physiological scores. METHODS: A posthoc single-center observational cohort study of prospectively collected vital signs on acutely admitted medical patients to a Danish hospital. All adult patients arriving at an acute medical unit at a 450-bed regional teaching hospital were included. Upon arrival, we registered initial vital signs and only the first presentation in the study period was included. Patients were included from 1 June to 31 October 2012. All-cause 24-h mortality and overall in-hospital mortality were used as endpoints. A discriminatory power above 0.8 was considered acceptable. RESULTS: 5784 patients were included with a median age of 67 (49-78) years, 32 (0.6%) died within 24h and 161 (2.8%) while admitted. Discriminatory power for 24h mortality was above 0.8 for all scores (except the Groarke score (0.587)) and highest for the Worthing score (0.847). The discriminatory power for predicting overall in-hospital mortality was highest for the Goodacre and Worthing scores (0.810 and 0.800 respectively) but below 0.8 for the remaining scores. CONCLUSION: The Goodacre score and the Worthing physiological score have good discriminatory power at identifying patients at increased risk of 24-h and in-hospital mortality in our setting.

Challenges in out-of-hospital cardiac arrest - A study combining closed-circuit television (CCTV) and medical emergency calls.

UNLABELLED: The aim of this study was to explore challenges in recognition and initial treatment of out-of-hospital cardiac arrest (OHCA) by using closed-circuit television (CCTV) recordings combined with audio recordings from emergency medical calls. METHOD: All OHCA captured by CCTV in the Capital Region of Denmark, 15 June 2013-14 June 2014, were included. Using a qualitative approach based on thematic analysis, we focused on the interval from the victim's collapse to the arrival of the ambulance. RESULTS: Based on the 21 CCTV recordings collected, the main challenges in OHCA seemed to be situation awareness, communication and attitude/approach. Situation awareness among bystanders and the emergency medical dispatchers (dispatcher) differed. CCTV showed that bystanders other than the caller, were often physically closer to the victim and initiated cardiopulmonary resuscitation (CPR). Hence, information from the dispatcher had to pass through the caller to the other bystanders. Many bystanders passed by or left, leaving the resuscitation to only a few. In addition, we observed that the callers did not delegate tasks that could have been performed more effectively by other bystanders, for example, receiving the ambulance or retrieving an Automated External Defibrillator (AED). CONCLUSION: CCTV combined with audio recordings from emergency calls can provide unique insights into the challenges of recognition and initial treatment of OHCA and can improve understanding of the situation. The main barriers to effective intervention were situation awareness, communication and attitude/approach. Potentially, some of these challenges could be minimized if the dispatcher was able to see the victim and the bystanders at the scene. A team approach, with the dispatcher responsible for the role as team leader of a remote resuscitation team of a caller and bystanders, may potentially improve treatment of OHCA.

[Crowdsourcing is a new method for generating data for scientific research]. / Crowdsourcing er en ny metode til indsamling af data til videnskabelige undersøgelser.

Crowdsourcing (CS) is a rapidly emerging method in scientific research. In CS, large groups of people generate new data or try to find solutions to specific research questions, mainly by online collaboration. Examples of the current use of CS in medicine include disease surveillance as well as diagnosis of rare conditions. CS techniques are rapid, low cost and geographically independent - traits lacking in traditional types of study design. However, CS as a method has not yet found its place in the evidence rating scale and a standard for conducting and reporting CS studies does not yet exist.

Current use of ultrasound for central vascular access in children and infants in the Nordic countries--a cross-sectional study.

PURPOSE: The use of ultrasound (US) guidance for central vascular access in children has been advocated as a safer approach compared to traditional landmark techniques. We therefore collected data on the current use of US for central vascular access in children and infants in the Nordic countries. METHODS: A cross-sectional survey using an online questionnaire was distributed to one anaesthesiologist at every hospital in the Nordic countries; a total of 177 anaesthesiologists were contacted from July till August 2012. RESULTS: The use of US for placing central venous catheters (CVCs) seems widespread across the Nordic countries. Close to 80% of respondents were using it "almost always" or "frequently" across all paediatric age groups for internal jugular vein cannulation. US was least frequently used when catheterizing the subclavian vein. The two most common reasons given when not using US were lack of training followed by lack of equipment. We found no difference in the use of US between high-volume centres and low-volume centres. (High-volume centres placed paediatric CVCs at least weekly.). CONCLUSIONS: US was commonly used for cannulation of the internal jugular vein but infrequently for the subclavian vein. A lack of training seems to be a barrier for further increasing the use of US. Establishing standardized training programmes based on current evidence should alleviate this.

Hypoalbuminemia is a strong predictor of 30-day all-cause mortality in acutely admitted medical patients: a prospective, observational, cohort study.

OBJECTIVE: Emergency patients with hypoalbuminemia are known to have increased mortality. No previous studies have, however, assessed the predictive value of low albumin on mortality in unselected acutely admitted medical patients. We aimed at assessing the predictive power of hypoalbuminemia on 30-day all-cause mortality in a cohort of acutely admitted medical patients. METHODS: We included all acutely admitted adult medical patients from the medical admission unit at a regional teaching hospital in Denmark. Data on mortality was extracted from the Danish Civil Register to ensure complete follow-up. Patients were divided into three groups according to their plasma albumin levels (0-34, 35-44 and ≥45 g/L) and mortality was identified for each group using Kaplan-Meier survival plot. Discriminatory power (ability to discriminate patients at increased risk of mortality) and calibration (precision of predictions) for hypoalbuminemia was determined. RESULTS: We included 5,894 patients and albumin was available in 5,451 (92.5%). A total of 332 (5.6%) patients died within 30 days of admission. Median plasma albumin was 40 g/L (IQR 37-43). Crude 30-day mortality in patients with low albumin was 16.3% compared to 4.3% among patients with normal albumin (p<0.0001). Patients with low albumin were older and admitted for a longer period of time than patients with a normal albumin, while patients with high albumin had a lower 30-day mortality, were younger and were admitted for a shorter period. Multivariable logistic regression analyses confirmed the association of hypoalbuminemia with mortality (OR: 1.95 (95% CI: 1.31-2.90)). Discriminatory power was good (AUROC 0.73 (95% CI, 0.70-0.77)) and calibration acceptable. CONCLUSION: We found hypoalbuminemia to be associated with 30-day all-cause mortality in acutely admitted medical patients. Used as predictive tool for mortality, plasma albumin had acceptable discriminatory power and good calibration.

Full-text publication of abstracts in emergency medicine in Denmark.

INTRODUCTION: Abstracts presented at medical conferences or scientific meetings should ideally be published as full-text articles in peer-reviewed journals after initial presentation and feedback regardless of the findings. The aim of this survey was to determine the publication rate of papers presented at the Danish Emergency Medicine Conferences in 2009, 2010 and 2011. METHODS: Abstracts presented at the conferences were identified and authors contacted to obtain publication information. A further search was conducted using relevant databases. RESULTS: Publication rates for the 2009 and 2010 were approximately 30% (25-31.6%). The publication rate for the 2011 conference was 14.5% within 18 months with an additional 9% under review prior to publication. DISCUSSION: When comparing full-text publication rates from DEMC to previous international studies in EM Danish EM research community has similar publication rates. However, other more established specialties have higher publication levels. Knowledge of reasons for non-publication could lead to efforts to promote publication like funding; the possibility of discussion between authors and editors at conferences; "publication mentors"; and/or research courses provided by the Danish Society of Emergency Medicine.

Complication with intraosseous access: scandinavian users' experience.

INTRODUCTION: Intraosseous access (IO) is indicated if vascular access cannot be quickly established during resuscitation. Complication rates are estimated to be low, based on small patient series, model or cadaver studies, and case reports. However, user experience with IO use in real-life emergency situations might differ from the results in the controlled environment of model studies and small patient series. We performed a survey of IO use in real-life emergency situations to assess users' experiences of complications. METHODS: An online questionnaire was sent to Scandinavian emergency physicians, anesthesiologists and pediatricians. RESULTS: 1,802 clinical cases of IO use was reported by n=386 responders. Commonly reported complications with establishing IO access were patient discomfort/pain (7.1%), difficulties with penetration of periosteum with IO needle (10.3%), difficulties with aspiration of bone marrow (12.3%), and bended/broken needle (4.0%). When using an established IO access the reported complications were difficulties with injection fluid and drugs after IO insertion (7.4%), slow infusion (despite use of pressure bag) (8.8%), displacement after insertion (8.5%), and extravasation (3.7%). Compartment syndrome and osteomyelitis occurred in 0.6% and 0.4% of cases respectively. CONCLUSION: In users' recollection of real-life IO use, perceived complications were more frequent than usually reported from model studies. The perceived difficulties with using IO could affect the willingness of medical staff to use IO. Therefore, user experience should be addressed both in education of how to use, and research and development of IOs.

[Danish emergency departments are not staffed by consultants 24/7]. / Speciallægen er ikke i front på de danske akutafdelinger.

The Danish health care system is undergoing a major reorganisation, resulting in fewer emergency departments (ED) with consultants in attendance 24/7. This questionnaire-based study evaluates the status of the reorganisation with emphasis on physician attendance and recruitment. 76% of the EDs are not staffed by consultants 24/7, 51% report difficulties in recruiting qualified personnel and 33% report problems connected to retaining them. 71% believe that a specialty in emergency medicine could help solve these problems. Danish EDs do not comply with the visions of the reorganisation plan.