Puukotukset Turussa 18.8.2017 - Ensihoitolääkärin näkökulma

Teema : uhat ja poikkeusolo

Miksi ambulanssi ei kuljeta potilasta sairaalaan?

Suomessa tapahtuu vuosittain noin 800 000 ensihoitotehtävää, joista Varsinais-Suomessa noin 63 000. Ensihoito koskettaakin vuosittain joko suoraan tai välillisesti isoa määrää ihmisiä. Kaikista ensihoidon potilaista noin 40 prosenttia jätetään potilaan tutkimisen ja tarvittavan ensihoidon jälkeen kuljettamatta jatkohoitoon. Perinteisesti ensihoidon potilaat on kuljetettu sairaalaan, jolloin ensihoidon sijaan puhuttiin sairaankuljetuksesta. Nykyään keskeinen lähtökohta on, että hoidon tarpeen arvio ja ensihoito toteutetaan ensihoitajien toimesta potilaan luona. Menettely vähentää päivystysten ruuhkautumista, millä varmistetaan riittävät resurssit kriittisesti sairastuneiden potilaiden hoitamiseen. Ensihoidon ydintehtävänä on jatkossakin hoitaa kriittisesti sairastuneita tai vammautuneita potilaita. Ensihoidon rooli on kuitenkin muuttunut muun muassa terveydenhuollon päivystyspisteiden keskittämisen myötä. Monella alueella ambulanssi saattaa olla ainoa saatavilla oleva terveydenhuollon palvelu ilta- ja yöaikaan. Näin ollen ensihoidon tehtävät sisältävät entistä enemmän kiireettömiä tehtäviä hätätilanteiden sijaan. Tutkimusten mukaan ensihoidon potilaat ovatkin usein hyvässä kunnossa

Reorganisation of stroke care in prehospital emergency medical services : results through transformative learning

Background: Rapid recanalisation is important when treating ischaemic stroke patients. In Finland, the reorganisation of the prehospital emergency medical system and the establishment of emergency medicine as an independent speciality occurred some years ago. These reforms offered the opportunity to develop new prehospital and in-hospital pathways for stroke patients. Methods: In this retrospective study, we examined the immediate impact of implementing a new operating model in prehospital stroke care. We introduced a modified “load-and-go” model using a transformative learning process. We observed the immediate effects of the reorganisation by comparing prehospital time intervals three months before and three months after the reorganisation. Results: The new operating model was implemented using a transformative learning process. There was an immediate reduction of 35.1% from 21.4 to 13.9 minutes (P < 0.001) in the median on-scene time and of 18.2% from 52.7 to 43.1 minutes (P < 0.05) in the median total time, i.e. the time interval between the alarm from the dispatch centre to patient hand-over to ED. Conclusion: By using a transformative learning process in implementing a modified load-and-go operation model in the EMS, we could immediately reduce median on-scene time and median total time in the treatment of acute stroke patients.publishedVersionPeer reviewe

Cardiopulmonary resuscitation in adults over 80 : outcome and the perception of appropriateness by clinicians

OBJECTIVES: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out‐of‐hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN: Subanalysis of an international multicenter cross‐sectional survey (REAPPROPRIATE). SETTING: Out‐of‐hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the “appropriate” subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the “uncertain” subgroup, and 2 of 107 (1.9%) in the “inappropriate” subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non‐shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non‐shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39–45, 201