The capabilities and scope of practice requirements of advanced life support undertaking critical care transfers: a Delphi study

Abstract: Background. Critical care transfers (CCT) refer to the high level of care given during transport (via ambulance, helicopter or fixed-wing aircraft) to patients who are of high acuity. In South Africa (SA), Advanced Life Support (ALS) paramedics undertake CCTs. The scope of ALS in SA has no extended protocol regarding procedures or medications in terms of dealing with these CCTs. Aim. The aim of this study was to obtain the opinions of several experts in fields pertaining to critical care and transport and to gain consensus on the skills and scope of practice requirements of paramedics undertaking CCTs in the SA setting. Methods. A modified Delphi study consisting of three rounds was undertaken using an online survey platform. A heterogeneous sample (n=7), consisting of specialists in the fields of anaesthesiology, emergency medicine, internal medicine, critical care, critical care transport and paediatrics, was asked to indicate whether, in their opinion, selected procedures and medications were needed within the scope of paramedics completing CCTs. Results. After three rounds, consensus was obtained in 70% (57/81) of procedures and medications. Many of these items are not currently within the scope of paramedics’ training. The panel felt that paramedics undertaking these transfers should have additional postgraduate training that is specific to critical care. Conclusion. Major discrepancies exist between the current scope of paramedic practice and the suggested required scope of practice for CCTs. An extended scope of practice and additional training should be considered for these practitioners

Modeling the behavior of the helmsman steering a ship

A supertanker is considered as a nonlinear system which responds very slowly to changes in the rudder position. Moreover this type of ship is often unstable in loaded condition. In order to model the helmsman's behavior, a number of tests were performed using a ship maneuvering simulator. The trained subjects had to steer a 200,000 tons tanker along a varying course. The results obtained from these trials are presented

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector

Background. South Africa (SA) has a shortage of dedicated neonatal critical care services, which are mostly concentrated in urban areas, thus illustrating the need for neonatal critical care transport (CCT) services. Neonates who are transported by teams without the requisite experience and knowledge in neonatal care are at risk of severe adverse events during transport. This has led to the development of dedicated CCT teams by some emergency medical services. There is a paucity of national literature describing the neonatal population who undergo CCT in dedicated services.Objectives. To describe a sample of neonates who underwent CCT transfer by dedicated CCT services in the private sector in SA.Methods. This observational cohort study with a retrospective descriptive design sampled all neonatal transfers completed during 1 year (1 January 2017 - 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in SA. Data were extracted from patient report forms by trained data extractors, and subjected to descriptive analysis.Results. A total of 444 neonates were transferred between the two services. A total of 760 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent diagnosis was respiratory distress syndrome (n=139, 31%), followed by congenital heart defects (n=123, 28%) and prematurity (n=81, 18%). Patients had an average of ~4 attachments, with the most prevalent being patient monitoring (n=677, 152%). Just under half (n=182, 41%) of patients required ventilatory support. A total of 422 medications were required during transport, yielding a rate of ~1 medication or infusion per neonate transported. The most common infusion was maintenance (n=199, 45%), while almost 1 in 10 neonates required inotropic support (n=33, 7%).Conclusions. This study provides insight into the demographics, most prevalent diagnoses, and interfacility transfer monitoring needs of neonates being transported in SA by two private dedicated CCT services. The results of this study should be used to inform future specialised neonatal CCT courses and qualifications, as well as the scopes of practice of providers transporting neonates

Influence of the gate leakage current on the stability of organic single-crystal field-effect transistors

We investigate the effect of a small leakage current through the gate insulator on the stability of organic single-crystal field-effect transistors (FETs). We find that, irrespective of the specific organic molecule and dielectric used, leakage current flowing through the gate insulator results in an irreversible degradation of the single-crystal FET performance. This degradation occurs even when the leakage current is several orders of magnitude smaller than the source-drain current. The experimental data indicate that a stable operation requires the leakage current to be smaller than $10^{-9} \ \mathrm{A/cm}^2$. Our results also suggest that gate leakage currents may determine the lifetime of thin-film transistors used in applications.Comment: submitted to Appl. Phys. Let

Novel variations in spatial relations between the facial nerve and superficial temporal and maxillary veins

Variations in the relationship of the retromandibular vein to the facial nerve have been widely reported due to their relevance for surgical approaches in parotid, osteotomy and mandibular condyle surgery. In the context of the retromandibular retroparotid approach, remaining deep to the retromandibular vein is advised to decrease the likelihood of encountering the facial nerve during mandibular condyle surgery. In the present report, an unusual variant of the superficial temporal vein lying superficial to the facial nerve is described. This represents a variation of the venous branching pattern within the parotid gland, whereby the superficial temporal vein joins the maxillary vein inferior to its usual communication. These findings are discussed in the context of commonly used surgical approaches to the mandible for condylar trauma or osteotomy surgery

A national retrospective descriptive analysis of critical care transfers in the private sector in South Africa

Background. Critical care transfers (CCTs) are necessitated by the growing prevalence of high-acuity patients who require upgrade of care to multidisciplinary teams from less-equipped referring facilities. Owing to the high acuity of the critical care patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The inherent understanding of the potential effects, and therefore the needs of the critical care patient during transfer, are affected owing to the paucity of international, but more specifically, local data relating to CCTs. Objectives. To describe a cohort of patients who underwent CCT by dedicated critical care retrieval services (CCRS) in the private sector in South Africa (SA). Methods. This retrospective, descriptive study sampled all paediatric and adult CCTs completed over a 1-year period (1 January 2017 - 31 December 2017) from the dedicated CCRS of two national emergency medical services in SA. All neonatal patients were excluded. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis. Results. A total of 1 839 patients were transferred between the two services. A total of 3 143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was cardiovascular disease (n=457, 25%), followed by infection (n=180, 10%) and head injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2 856, 155%), peripheral intravenous access (n=794, 43%) and mechanical ventilation (n=445, 24%). A total of 2 152 instances of medication infusion or administration were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were central nervous system depressants (n=588, 32%), followed by analgesics (n=482, 26%) and inotropic or vasoactive agents (n=320, 17%). Conclusion. This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in SA by two private dedicated CCRS. The results of this study may be used to inform future specialised critical care transport courses and qualifications, equipment procurement and scopes of practice for providers undertaking critical care transfers

The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: A retrospective chart review

Background. Each year, ~89 000 (180/100 000) new cases of head injury are reported in South Africa (SA), with the majority of patients being in the economically active population. Hypotension and hypoxaemia significantly increase the morbidity and mortality in patients who have suffered a traumatic brain injury (TBI). Cerebral tissue is particularly vulnerable to these secondary insults in the period immediately following a TBI, emphasising the importance of prehospital care in TBI.Objective. To establish the prevalence of prehospital hypotension and hypoxaemia in moderate to severe blunt TBI in greater Johannesburg, Gauteng, SA.Methods. The records of adult patients who sustained a moderate to severe TBI between 1 January and 31 December 2011 were retrospectively reviewed for hypotension (systolic blood pressure <90 mmHg) and hypoxaemia (oxygen saturation <90%) during their prehospital phase of care. These results were subject to descriptive analysis.Results. A total of 299 records were identified, 66 of which met the inclusion criteria. The prevalence of prehospital hypotension and hypoxaemia were 33.3% (n=22) and 37.9% (n=25), respectively, while 21.2% (n=14) of patients suffered double insults of hypotension and hypoxaemia. Hypotension and hypoxaemia were associated with haemorrhage (p=0.011) and chest injuries (p=0.001), respectively.Conclusion. The prevalence of hypotension in this study was similar to that observed in international studies, but the prevalence of hypoxaemia was much higher. There is a need for local guidelines to be developed to inform the quality of TBI care in the context of the developing world.