The Impact of Emergency Medical Service Physicians on Patient Outcomes : with a focus on prehospital traumatic brain injury

Ensihoidolla tarkoitetaan äkillisesti sairastuneen tai loukkaantuneen potilaan kiireellistä hoitoa ja kuljettamista jatkohoitoon. Suomen ensimmäinen lääkäriyksikkö perustettiin Helsingissä vuonna 1972. 1980-luvulla lääkäriyksikkötoiminta laajeni ja ensimmäinen lääkärihelikopteri aloitti toimintansa vuonna 1992. Ensihoitoa sekä ensihoitojärjestelmän että sen osien toimintaa ja toiminnan tehokkuutta on haastavaa tutkia. Tämän väitöskirjan tavoitteena oli arvioida ensihoitolääkärin vaikutusta potilaan ennusteeseen ja erityisenä tutkimuskohteena olivat aivovammapotilaat. Väitöskirja koostuu neljästä osatyöstä, joista ensimmäinen käsitteli äkillisesti sairastuneen tai loukkaantuneen potilaan hoitoa ja ennustetta viiden vuoden (2007- 2011) ajanjaksolla (I). Tutkimuskohteena oli ensihoitolääkärin hoitamien 483:n äkillisesti sairastuneen tai loukkaantuneen potilaan pitkäaikaisennuste. Vuoden kestäneen seurantavaiheen aikana potilaiden kuolleisuus oli 35 % ja hyvään neurologiseen lopputulokseen (määriteltynä paluuna itsenäiseen elämään) toipui 55 % potilaista. Eloonjäänneistä 85 % ja valtaosa nuorista ikäryhmistä (määriteltynä alle 60 vuotiaat) toipuivat hyvin. Kolme muuta osatyötä keskittyvät aivovammapotilaisiin ja ensihoitolääkärin vaikutuksen arvioimiseksi vakavien aivovammapotilaiden hoito ja toipuminen selvitettiin kahdesta tutkimuskohteesta (Helsingin ja Uudenmaan sekä Pirkanmaan alueelta) vuosilta 2005-2010 ja 2012-2015 kolmessa eri asetelmassa: ensihoitojärjestelmä ilman ja ensihoitolääkärin kanssa (II), ennen ja jälkeen-asetelma (III) sekä kohteessa olleen ensihoitolääkärin vaikutus (IV). Vuoden 2011 tietoja ei sisällytetty mukaan tutkimuksiin johtuen Pirkanmaan lääkärihelikopterin aloituksesta vuonna 2011 ja sen aiheuttamasta vaikutuksesta paikalliseen ensihoitojärjestelmään. Kahden alueen erityyppisesti järjestettyjen ensihoitojärjestelmien vertailussa todettiin ensihoitolääkärin vähentävän vakavien aivovammapotilaiden kuolleisuutta ja monimuuttuja-analyysissä ensihoitojärjestelmä ilman ensihoitolääkäriä todettiin kuolleisuuteen vaikuttavana tekijänä, kun potilaat ikävakioitiin (II). Tulosten perusteella myös ensihoitolääkärin hoitamien potilaiden neurologinen toipuminen on parempaa ja vakioimattomassa analyysissä ensihoitolääkäri, nuorempi ikä ja turvattu hengitystie ovat yhteydessä hyvään neurologiseen toipumiseen (III). Edellisiin tuloksiin perustuen koottua tietoa vakavien aivovammapotilaiden hoidosta jatkoanalysoitiin binäärisellä logistisella regressioanalyysillä (IV). Kuolleisuus 651 potilaan osalta ja neurologinen lopputulos 634 potilaan osalta analysoitiin. Vakioimattomassa analyysissa korkeampi ikä, matalampi GCS kohdattaessa ja ensihoito ilman ensihoitolääkäriä olivat muuttujia, jotka olivat yhteydessä korkeampaan kuolleisuuteen. Monimuuttuja-analyysissa nämä muuttujat sekä matala verenpaine säilyivät kuoleman riskitekijöinä. Hyvään neurologiseen toipumiseen yhteydessä olevat tekijät olivat nuorempi ikä, korkeampi GCS kohdattaessa ja ensihoitolääkärin antama hoito. Vastaava tulos havaittiin myös monimuuttuja-analyysissa, jossa myös matala verenpaine oli yhteydessä huonoon ennusteeseen. Väitöskirjan johtopäätöksinä voidaan todeta, että ensihoitolääkärin hoitamien äkillisesti sairastuneiden tai loukkaantuneiden potilaiden pitkäaikaisennuste on hyvä ja ensihoitolääkärin mukanaolo on yhteydessä aivovammapotilaan vähäisempään kuolleisuuteen ja parempaan ennusteeseen.Out-of-hospital emergency medical services (EMS), also known as prehospital EMS, typically refer to the delivery of medical care at the site of the adverse medical event. The first physician-staffed EMS-unit in Finland was introduced in the year 1972 in Helsinki. During the 1980’s other physician-staffed EMS units were founded and the first physician-staffed helicopter emergency medical service (HEMS) unit was introduced in 1992. As EMS systems and prehospital care are difficult to evaluate, the true efficacy and value of such systems are difficult to determine. This thesis evaluates the impact of physician-staffed EMS on patient outcome with a focus on prehospital traumatic brain injury (TBI). The thesis is based on four original publications. The first studied the long-term outcome of 483 critically ill or severely injured patients treated on-scene by EMS physicians over a five-year (2007-2011) period (I). The patients’ one-year mortality was 35 % and good neurological recovery (defined as the ability to live an independent life) was found in 55 % of the patients. After the incident, 85 % of the long-term survivors as well as most of the patients in the younger age groups (below 60 years of age) recovered well neurologically. To evaluate the role of EMS physician involvement, the prehospital treatment and outcomes of patients with severe TBI from 2005-2010 and 2012–2015 in two study locations (the Helsinki and Uusimaa region and in Pirkanmaa region in Finland) were determined in three different scenarios: paramedic- versus physician- staffed EMS (II), before and after the introduction of physicians into paramedic EMS (III) and pooled data considering the effect of an on-scene physician on the TBI patients’ outcome (IV). The data covering 2011 were excluded as a physician- staffed HEMS was implemented in the Pirkanmaa Hospital District that year and had a significant impact on the local EMS. When two regions with differently structured EMS systems were compared, the mortality was lower with EMS physician present on-scene, and the EMS system without EMS physician remained as a risk factor for mortality in the multivariable analysis after the patients were adjusted by age (II). The results also show better neurological outcomes in patients treated by EMS physicians, and in a univariate analysis of EMS physicians, a lower age and secured airway were associated with good neurological outcomes (III). Based on these findings, the gathered TBI patient data were further analysed with a binary logistic regression analysis (IV) as the mortality data for 651 patients and neurological outcome data for 634 patients were available for analysis. In the univariate analysis, increasing age, lower on-scene Glasgow Coma Scale (GCS) and prehospital treatment without the presence of EMS physicians were factors associated with higher mortality. In a multivariable analysis, these variables, with the addition of hypotension, remained significant factors for mortality. Factors associated with good neurological outcomes in the univariate analysis were lower age, higher on-scene GCS and the presence of an on-scene EMS physician. In the multivariable analysis, all these factors remained significant for good outcomes, while hypotension was associated with poor outcomes. Based on these studies, the following conclusions can be drawn: The overall prehospital one-year mortality of critically ill or severely injured patients treated on- scene by EMS physicians can be considered low, and prehospital on-scene EMS physicians treating severe TBI patients is associated with lower mortality and better neurological outcomes

Supporting Eyes-Free Human–Computer Interaction with Vibrotactile Haptification

The sense of touch is a crucial sense when using our hands in complex tasks. Some tasks we learn to do even without sight by just using the sense of touch in our fingers and hands. Modern touchscreen devices, however, have lost some of that tactile feeling while removing physical controls from the interaction. Touch is also a sense that is underutilized in interactions with technology and could provide new ways of interaction to support users. While users are using information technology in certain situations, they cannot visually and mentally focus completely during the interaction. Humans can utilize their sense of touch more comprehensively in interactions and learn to understand tactile information while interacting with information technology. This thesis introduces a set of experiments that evaluate human capabilities to understand and notice tactile information provided by current actuator technology and further introduces a couple of examples of haptic user interfaces (HUIs) to use under eyes-free use scenarios. These experiments evaluate the benefits of such interfaces for users and concludes with some guidelines and methods for how to create this kind of user interfaces. The experiments in this thesis can be divided into three groups. In the first group, with the first two experiments, the detection of vibrotactile stimuli and interpretation of the abstract meaning of vibrotactile feedback was evaluated. Experiments in the second group evaluated how to design rhythmic vibrotactile tactons to be basic vibrotactile primitives for HUIs. The last group of two experiments evaluated how these HUIs benefit the users in the distracted and eyes-free interaction scenarios. The primary aim for this series of experiments was to evaluate if utilizing the current level of actuation technology could be used more comprehensively than in current-day solutions with simple haptic alerts and notifications. Thus, to find out if the comprehensive use of vibrotactile feedback in interactions would provide additional benefits for the users, compared to the current level of haptic interaction methods and nonhaptic interaction methods. The main finding of this research is that while using more comprehensive HUIs in eyes-free distracted-use scenarios, such as while driving a car, the user’s main task, driving, is performed better. Furthermore, users liked the comprehensively haptified user interfaces

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome

Background: Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients. Methods: Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of Results: The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome. Conclusion: Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.Peer reviewe

Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services

Background: Traumatic brain injury (TBI) is one of the leading causes of death and permanent disability. Emergency Medical Services (EMS) personnel are often the first healthcare providers attending patients with TBI. The level of available care varies, which may have an impact on the patient's outcome. The aim of this study was to evaluate mortality and neurological outcome of TBI patients in two regions with differently structured EMS systems. Methods: A 6-year period (2005 - 2010) observational data on pre-hospital TBI management in paramedic-staffed EMS and physician-staffed EMS systems were retrospectively analysed. Inclusion criteria for the study were severe isolated TBI presenting with unconsciousness defined as Glasgow coma scale (GCS) score Results: During the 6-year study period a total of 458 patients met the inclusion criteria. One-year mortality was higher in the paramedic-staffed EMS group: 57 % vs. 42 %. Also good neurological outcome was less common in patients treated in the paramedic-staffed EMS group. Discussion: We found no significant difference between the study groups when considering the secondary brain injury associated vital signs on-scene. Also on arrival to ED, the proportion of hypotensive patients was similar in both groups. However, hypoxia was common in the patients treated by the paramedic-staffed EMS on arrival to the ED, while in the physician-staffed EMS almost none of the patients were hypoxic. Prehospital intubation by EMS physicians probably explains this finding. Conclusion: The results suggest to an outcome benefit from physician-staffed EMS treating TBI patients.Peer reviewe

The Impact of Emergency Medical Service Physicians on Patient Outcomes : with a focus on prehospital traumatic brain injury

Ensihoidolla tarkoitetaan äkillisesti sairastuneen tai loukkaantuneen potilaan kiireellistä hoitoa ja kuljettamista jatkohoitoon. Suomen ensimmäinen lääkäriyksikkö perustettiin Helsingissä vuonna 1972. 1980-luvulla lääkäriyksikkötoiminta laajeni ja ensimmäinen lääkärihelikopteri aloitti toimintansa vuonna 1992. Ensihoitoa sekä ensihoitojärjestelmän että sen osien toimintaa ja toiminnan tehokkuutta on haastavaa tutkia. Tämän väitöskirjan tavoitteena oli arvioida ensihoitolääkärin vaikutusta potilaan ennusteeseen ja erityisenä tutkimuskohteena olivat aivovammapotilaat. Väitöskirja koostuu neljästä osatyöstä, joista ensimmäinen käsitteli äkillisesti sairastuneen tai loukkaantuneen potilaan hoitoa ja ennustetta viiden vuoden (2007- 2011) ajanjaksolla (I). Tutkimuskohteena oli ensihoitolääkärin hoitamien 483:n äkillisesti sairastuneen tai loukkaantuneen potilaan pitkäaikaisennuste. Vuoden kestäneen seurantavaiheen aikana potilaiden kuolleisuus oli 35 % ja hyvään neurologiseen lopputulokseen (määriteltynä paluuna itsenäiseen elämään) toipui 55 % potilaista. Eloonjäänneistä 85 % ja valtaosa nuorista ikäryhmistä (määriteltynä alle 60 vuotiaat) toipuivat hyvin. Kolme muuta osatyötä keskittyvät aivovammapotilaisiin ja ensihoitolääkärin vaikutuksen arvioimiseksi vakavien aivovammapotilaiden hoito ja toipuminen selvitettiin kahdesta tutkimuskohteesta (Helsingin ja Uudenmaan sekä Pirkanmaan alueelta) vuosilta 2005-2010 ja 2012-2015 kolmessa eri asetelmassa: ensihoitojärjestelmä ilman ja ensihoitolääkärin kanssa (II), ennen ja jälkeen-asetelma (III) sekä kohteessa olleen ensihoitolääkärin vaikutus (IV). Vuoden 2011 tietoja ei sisällytetty mukaan tutkimuksiin johtuen Pirkanmaan lääkärihelikopterin aloituksesta vuonna 2011 ja sen aiheuttamasta vaikutuksesta paikalliseen ensihoitojärjestelmään. Kahden alueen erityyppisesti järjestettyjen ensihoitojärjestelmien vertailussa todettiin ensihoitolääkärin vähentävän vakavien aivovammapotilaiden kuolleisuutta ja monimuuttuja-analyysissä ensihoitojärjestelmä ilman ensihoitolääkäriä todettiin kuolleisuuteen vaikuttavana tekijänä, kun potilaat ikävakioitiin (II). Tulosten perusteella myös ensihoitolääkärin hoitamien potilaiden neurologinen toipuminen on parempaa ja vakioimattomassa analyysissä ensihoitolääkäri, nuorempi ikä ja turvattu hengitystie ovat yhteydessä hyvään neurologiseen toipumiseen (III). Edellisiin tuloksiin perustuen koottua tietoa vakavien aivovammapotilaiden hoidosta jatkoanalysoitiin binäärisellä logistisella regressioanalyysillä (IV). Kuolleisuus 651 potilaan osalta ja neurologinen lopputulos 634 potilaan osalta analysoitiin. Vakioimattomassa analyysissa korkeampi ikä, matalampi GCS kohdattaessa ja ensihoito ilman ensihoitolääkäriä olivat muuttujia, jotka olivat yhteydessä korkeampaan kuolleisuuteen. Monimuuttuja-analyysissa nämä muuttujat sekä matala verenpaine säilyivät kuoleman riskitekijöinä. Hyvään neurologiseen toipumiseen yhteydessä olevat tekijät olivat nuorempi ikä, korkeampi GCS kohdattaessa ja ensihoitolääkärin antama hoito. Vastaava tulos havaittiin myös monimuuttuja-analyysissa, jossa myös matala verenpaine oli yhteydessä huonoon ennusteeseen. Väitöskirjan johtopäätöksinä voidaan todeta, että ensihoitolääkärin hoitamien äkillisesti sairastuneiden tai loukkaantuneiden potilaiden pitkäaikaisennuste on hyvä ja ensihoitolääkärin mukanaolo on yhteydessä aivovammapotilaan vähäisempään kuolleisuuteen ja parempaan ennusteeseen.Out-of-hospital emergency medical services (EMS), also known as prehospital EMS, typically refer to the delivery of medical care at the site of the adverse medical event. The first physician-staffed EMS-unit in Finland was introduced in the year 1972 in Helsinki. During the 1980’s other physician-staffed EMS units were founded and the first physician-staffed helicopter emergency medical service (HEMS) unit was introduced in 1992. As EMS systems and prehospital care are difficult to evaluate, the true efficacy and value of such systems are difficult to determine. This thesis evaluates the impact of physician-staffed EMS on patient outcome with a focus on prehospital traumatic brain injury (TBI). The thesis is based on four original publications. The first studied the long-term outcome of 483 critically ill or severely injured patients treated on-scene by EMS physicians over a five-year (2007-2011) period (I). The patients’ one-year mortality was 35 % and good neurological recovery (defined as the ability to live an independent life) was found in 55 % of the patients. After the incident, 85 % of the long-term survivors as well as most of the patients in the younger age groups (below 60 years of age) recovered well neurologically. To evaluate the role of EMS physician involvement, the prehospital treatment and outcomes of patients with severe TBI from 2005-2010 and 2012–2015 in two study locations (the Helsinki and Uusimaa region and in Pirkanmaa region in Finland) were determined in three different scenarios: paramedic- versus physician- staffed EMS (II), before and after the introduction of physicians into paramedic EMS (III) and pooled data considering the effect of an on-scene physician on the TBI patients’ outcome (IV). The data covering 2011 were excluded as a physician- staffed HEMS was implemented in the Pirkanmaa Hospital District that year and had a significant impact on the local EMS. When two regions with differently structured EMS systems were compared, the mortality was lower with EMS physician present on-scene, and the EMS system without EMS physician remained as a risk factor for mortality in the multivariable analysis after the patients were adjusted by age (II). The results also show better neurological outcomes in patients treated by EMS physicians, and in a univariate analysis of EMS physicians, a lower age and secured airway were associated with good neurological outcomes (III). Based on these findings, the gathered TBI patient data were further analysed with a binary logistic regression analysis (IV) as the mortality data for 651 patients and neurological outcome data for 634 patients were available for analysis. In the univariate analysis, increasing age, lower on-scene Glasgow Coma Scale (GCS) and prehospital treatment without the presence of EMS physicians were factors associated with higher mortality. In a multivariable analysis, these variables, with the addition of hypotension, remained significant factors for mortality. Factors associated with good neurological outcomes in the univariate analysis were lower age, higher on-scene GCS and the presence of an on-scene EMS physician. In the multivariable analysis, all these factors remained significant for good outcomes, while hypotension was associated with poor outcomes. Based on these studies, the following conclusions can be drawn: The overall prehospital one-year mortality of critically ill or severely injured patients treated on- scene by EMS physicians can be considered low, and prehospital on-scene EMS physicians treating severe TBI patients is associated with lower mortality and better neurological outcomes

Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

Background: After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients. Methods: This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score Results: Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p <0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome. Conclusion: The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period.Peer reviewe

Severe traumatic brain injury- physician provided pre-hospital care and early neurosurgical treatment are associated with improved survival

Non peer reviewe