Exploring individual and work organizational peculiarities of working in emergency medical communication centers in Norway- a qualitative study.

BACKGROUND: Emergency Medical call-takers working in Emergency Medical Communication Centers (EMCCs) are addressing complex and potentially life threatening problems. The call-takers have to make fast decisions, responding to problems described in phone calls. Recent studies focus mainly on individual aspects of call-takers' work. The objectives of this study were to explore 1) What characterizes individual work performance of call takers in EMCCs? and 2) What characterizes work organizational factors call takers see as most relevant to the performance of their work? METHODS: The research is based upon in-depth interviews with call takers at three EMCCs in Norway (n = 19). Interviews were performed during the period May 2013 to September 2014. Data was analyzed using thematic analysis. RESULTS: Two main themes that related to individual work performance and to work organizational factors in EMCCs were identified, namely: 1) "Core technologies" and 2) "Environmental issues" . The theme "Core technologies" included the subthemes a) multiple tasks, b) critical incidents, and c) unpredictability. The theme "Environmental issues" included the subthemes a) lack of support, b) lack of resources, c) exposure to complaints, and d) an invisible service. CONCLUSION: At the individual level, multiple tasks, how to cope with critical incidents, and the unpredictability of daily work when calls are received, make the work of call takers both stressful and challenging. The individual call taker's ability to interprete the situation by intuition and experience when calls are received, is the main factor behind the peculiarities working in the centers at the individual level. At the organizational level, the lack of resources and managerial support seems to provoke concerns about the quality of services rendered by the centers. These aspects should be taken into account in the managing of these services, making them a more integrated part of the health service system.

Targeted simulation and education to improve cardiac arrest recognition and telephone assisted CPR in an emergency medical communication centre.

AIM: Recognition of cardiac arrest and prompt activation time by emergency medical dispatch are key process measures that have been associated with improved survival after out-of-hospital cardiac arrest (OHCA). The aim of this study is to improve recognition of OHCA and time to initiation of telephone assisted chest compressions in an emergency medical communication centre (EMCC). METHODS: A prospective, interventional study implementing targeted interventions in an EMCC. Interventions included: (1) lectures focusing on agonal breathing and interrogation strategy (2) simulation training (3) structured dispatcher feedback (4) web-based telephone assisted CPR training program. All ambulance-confirmed OHCA calls in the study period were assessed and relevant process and result measures were recorded pre- and post-intervention. Cardiac arrest was reported as (1) recognised, (2) not recognised or (3) delayed recognition. RESULTS: We included 331 and 230 calls pre- and post-intervention, respectively. Recognition of cardiac arrest improved significantly after intervention (89 vs. 95%, p=0.024). Delayed recognition was significantly reduced (21 vs. 6%, p>0.001), as was misinterpretation of agonal breathing (25 vs. 10%, p<0.001). Telephone assisted compressions increased (71% vs. 83%, p=0.002) whereas bystander performed ventilations decreased after intervention (23% vs. 15%, p=0.016). Time intervals for initiation of chest compression instructions (2.6 vs. 2.3min, p=0.042) and delivery of telephone assisted chest compressions (3.3 vs. 2.8min, p=0.015) were significantly shortened after intervention. CONCLUSION: Targeted simulation, education and feedback significantly improved recognition of OHCA and reduced time to first chest compression. Continuous measurement of key quality metrics can facilitate development of targeted education and training.

Factors impacting upon timely and adequate allocation of prehospital medical assistance and resources to cardiac arrest patients.

AIM: Explore, understand and address issues that impact upon timely and adequate allocation of prehospital medical assistance and resources to out-of-hospital cardiac arrest (OHCA) patients. METHODS: Mixed-methods design obtaining data for one year in three emergency medical communication centres (EMCC); Oslo-Akershus (OA), Vestfold-Telemark (VT) and Østfold (Ø). Data collection included quantitative data from analysis of dispatch logs, ambulance records and audio files. Qualitative data were collected through in-depth interviews and non-participant observations. RESULTS: OA-, VT- and Ø-EMCC responded to 1095 OHCAs and 579 of these calls were included for further analysis (333, 143 and 103, respectively). There were significant site differences in their recognition of OHCA (89, 94 and 78%, respectively, p<0.001), provision of CPR instructions (83, 83 and 61%, respectively, p<0.001), time from call answered to initial CPR instructions (1.4min (1.2, 1.6), 1.1min (0,9, 1.2) and 1.3 (1.2, 1.7) respectively, p=0.002). The most frequent reason for delayed or failed recognition of OHCA was misinterpretation of agonal breathing. Interviews and observations revealed individual differences in protocol use, interrogation strategy and assessment of breathing. Use of protocol was only part of decision making, dispatchers trusted their own clinical experience and intuition, and used assumptions about the patient and the situation as part of decision making. CONCLUSION: Agonal breathing continues to be the main barrier to recognition of cardiac arrest. Individual differences among dispatchers' strategies can directly impact on performance, mainly due to the wide definition of cardiac arrest and lack of uniform tools for assessment of breathing.

Pediatric Cardiac Arrest Due to Trauma.

Survival from pediatric cardiac arrest due to trauma has been reported to be 0.0%-8.8%. Some argue that resuscitation efforts in the case of trauma-related cardiac arrests are futile. We describe a successful outcome in the case of a child who suffered cardiac arrest caused by external traumatic airway obstruction. Our case illustrates how to deal with pediatric traumatic cardiac arrests in an out-of-hospital environment. It also illustrates how good clinical treatment in these situations may be supported by correct treatment after hospital admission when it is impossible to ventilate the patient to provide sufficient oxygen delivery to vital organs. This case relates to a lifeless child of 3-5 years, blue, and trapped by an electrically operated garage door. The first ambulance arrived to find several men trying to bend the frame and the door apart in order to extricate the child, who was hanging in the air with head and neck squeezed between the horizontally-moving garage door and the vertical door frame. One paramedic found a car jack and used it to push the door and the frame apart, allowing the lifeless child to be extricated. Basic life support was then initiated. Intubation was performed by the anesthesiologist without drugs. With FiO2 1.0 the first documented SaO2 was <50%. Restoration of Spontaneous Circulation was achieved after thirty minutes, and she was transported to the hospital. After a few hours she was put on venous-arterial ECMO for 5.5 days and discharged home after two months. Outpatient examinations during the rest of 2013 were positive, and the child found not to be suffering from any injuries, either physical or mental. The last follow-up in October 2014 demonstrated she had made a 100% recovery and she started school in August 2014.