[A 33-year old woman with heart arrest during Cesarean section].
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Cardiopulmonary Resuscitation↗
Biomedical subjects
Torben Wisborg
Publications and source records attributed to Torben Wisborg.
[Organisation of trauma services--major improvements over four years].
BACKGROUND: Despite recent developments in trauma care, it is estimated that 10 to 15% of deaths after injury are avoidable and caused by errors in the initial hospital phase of treatment. In 2000 it was found that a number of Norwegian hospitals lacked procedures and protocols. The situation in all hospitals delivering trauma care in Norway was reassessed. MATERIAL AND METHODS: In autumn of 2004, all 50 Norwegian trauma care hospitals were surveyed. Response was obtained from all. RESULTS: Trauma teams were found in 88% of all hospitals, compared to 52% in 2000. A parallel improvement was found in the use of paging criteria for trauma teams, use of trauma manuals and protocols, and designated patient charts. Targeted training of teams was done in 88% of the hospitals and 54 % had arranged practical drills of trauma teams in the six months prior to the survey. Only minor differences were found between hospitals at different levels. Systematic audits were performed in only 27% of hospitals. INTERPRETATION: A major improvement has taken place during four years, and it is now possible to implement national trauma care guidelines. There is still a need for improved use of audits and team training.
Clinical Competence↗
Training multiprofessional trauma teams in Norwegian hospitals using simple and low cost local simulations.
CONTEXT & OBJECTIVE: Norwegian hospitals' trauma teams are seldom exposed to severely injured patients. We developed and implemented a one-day multi-professional training course for hospital trauma teams in order to improve communication, cooperation and leadership. METHODS: Training courses were held in 28 Norwegian hospitals with learning objectives: improved team work, common understanding of treatment priorities and principles, communication skills, and threats to efficient communication. Two trauma teams in each hospital had two consecutive simulations in their hospital's own emergency room, as part of the course. Simulation was based on real cases, with a low-fidelity mannequin as patient. Participants completed questionnaires before and after the training course. RESULTS: A total of 2,860 trauma team members participated in the courses, of which 1,237 took part in the simulation. Independent of hospital size, the participants reported leadership and communication to be major obstacles during their last real trauma team participation. Immediately after the training, all participants reported highly fulfilled educational expectations and a high perception of learning, and taking part in the practical simulation improved the evaluation. Nurses scored their outcome significantly higher than physicians. Participants from minor hospitals reported as great a benefit from the training as personnel from major hospitals. CONCLUSIONS: Local team training is a feasible approach and team simulation offers an excellent opportunity to practise demanding and infrequent challenges. The simulation format makes it possible to integrate training on interpersonal skills as well as communication and leadership under stress. Continued requests for such training in Norway support this conclusion.
Cooperative Behavior↗
[ISnowmobiles and serious injuries in Western Finnmark].
BACKGROUND: Snowmobiles are increasingly popular. In Western Finnmark, Norway, there is now one snowmobile per five inhabitants, in the rest of Norway only one for each 110 inhabitants. Our clinical impression was that the frequency of injuries had increased. The aim of this study was to describe frequency and severity of snowmobile-related injuries through two winter seasons by the use of an existing injury registry. MATERIAL AND METHODS: Prospectively registered data from the injury registry at Hammerfest Hospital for the winter seasons 2002/2003 and 2003/2004 were analysed. RESULTS: Sixty-seven patients were registered with snowmobile-related injuries, mainly men between 15 and 35. The large majority of injuries were caused during recreational snowmobile driving, after sunset, and outside trails. Admission to hospital was necessary for 45 patients. The grading of severity was serious to critical in 13 victims; 2 persons were killed. The mechanism of injury was mainly loss of control over the vehicle. We have no reliable data concerning driving under the influence of ethanol. The rate of serious injuries per snowmobile was unchanged as compared to 1988-9, but the number of vehicles had increased by 30%. INTERPRETATION: Injuries related to snowmobiles are increasing in number and severity. They are mainly related to recreational use, especially in weekends and after sunset. The use of helmets, compulsory training, and expanded trails have not decreased the rate of accidents per vehicle. There is an urgent need for preventive measures.
Accidents↗
[A programme for boosting medical research in North Norway, 1992-2001].
BACKGROUND: Goals for the programme were recruitment of specialists and lowering turnover among them, generating new knowledge, quality assurance and professional development. Close to NOK 25 million were spent on this research programme in regional non-university hospitals over the 1992-2001 period. MATERIAL AND METHODS: 78 projects were funded, 77 responded to our questionnaire. RESULTS: 36 (47%) of respondents claim to have completed their projects, 5 (7%) have not, whereas 36 (47%) have ongoing projects. 70% of the projects have led to publications, 39% as part of doctoral theses, 61% have been done locally and 43 % also had other funding. In relation to the aims of the programme, those responding were very positive and 75 out of 77 suggested that a low-threshold, supportive programme of this type should be continued. INTERPRETATION: We conclude that the programme has had positive effects beyond the generation of new knowledge.
Biomedical Research↗
[Simulation--an efficient way of learning in graduate and continuous medical education].
BACKGROUND: Different types of simulators and simulated situations are being used in the training of doctors. Even though simulation as a learning method has been used in various areas such as aviation and oil industry, it has only recently been applied to medical education. Simulation seems to be very well suited in training for and building skills and experience with life threatening situation that are seldom seen. It represents no risk to the patient and it opens up for training in realistic scenarios. METHODS: Simulations are illustrated by using Miller's learning pyramid and Bloom's cognitive levels to show how different types of simulation can be used depending on the skills that are to be acquired. Team simulation is seen as a main factor for quality improvement in medicine. INTERPRETATION: Simulation and team simulation in particular is highly rated by participating professionals. There seems to be a problem in finding objective criteria for assessing the simulated scenarios and then to generalise the findings to real situations.
Clinical Competence↗
Prehospital tourniquets: there should be no controversy.
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Attitude of Health Personnel↗
[Clinical examination of the pelvis in patients with multiple traumas is unreliable].
BACKGROUND: The primary examination of a seriously injured patient is often done according to the Advanced Trauma Life Support concept. This concept calls for routine x-rays of the chest, pelvis and cervical spine. We have seen a tendency in Norway towards selective use of the pelvic film according to trauma mechanism and physical findings, even in patients with multiple traumas. MATERIAL AND METHODS: Four cases illustrate the risk of missing serious injuries in patients with multiple injuries if routine pelvic x-ray is omitted. A review of the literature confirms that routine pelvic x-ray may be omitted only if the patient is alert, has a negative physical pelvic examination, and no other distracting painful injuries. INTERPRETATION: Early x-ray of the pelvis should still be a routine in patients with multiple injuries, but may be omitted in patients with normal consciousness, no distracting painful injuries and no pain on examination of the pelvis.
Accidental Falls↗
[Sharp condemnation, not a cold professional assessment!].
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Humans↗
Training pre-hospital trauma care in low-income countries: the 'Village University' experience.
A prospective study was carried out of the health effects and sustainability of a low-cost trauma training program for non-graduate village healthcare workers. From 1996 to 1999, a core group of 44 health workers from mine-infested rural communities in Cambodia and Northern Iraq were trained and equipped to deliver low-cost life support to trauma victims. They in turn trained a network of 2800 layman village first responders. Training was done in makeshift camps at village level ('Village Universities'). A total of 813 patients were managed by the rural rescue system from 1997 to 1999. The mortality rate for trauma victims decreased from 22.6% in 1997 to 13.7% in 1999 (95% CI for difference 1.8% to 16.0%). Management by village first responders had a significant impact on in-field response times and trauma mortality. The rescue system replicated itself during the study period as an indicator of sustainability. The study showed that after trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue systems.
Allied Health Personnel↗
Prehospital thrombolysis in acute myocardial infarction in a very sparsely inhabited area in northern Norway.
This study reports the experience gained in prehospital thrombolysis in acute myocardial infarction in a sparsely inhabited remote area of northern Norway. The study was retrospective from 1992 to 1999. The area covered was 49 000 km2, with a population of 75 000. During the study period only one out of 19 municipalities offered prehospital thrombolysis by general practitioners. Treatment was therefore accomplished by the use of an existing anaesthesiologist-manned rescue helicopter in the absence of available alternatives. The objectives were to evaluate whether prehospital thrombolysis was feasible, and if this approach improved access to early thrombolysis. A total of 272 patients with cardiac-related diagnoses were treated; 91 were considered prehospitally to have an acute myocardial infarction. The median delay from the onset of chest pain until first contact with the health system was 4 hours and 6 minutes or 4 hours and 10 minutes. A total of 23 patients were thrombolysed by the rescue anaesthesiologist prehospitally and four by general practitioners, whereas 58 had contraindications, mainly the duration of chest pain being greater than 6 h (24). Twelve of the 23 patients experienced hypotension and arrhythmia after the administration of streptokinase. Prehospital thrombolysis was feasible, but in order to improve access for patients, all general practitioners or ambulance personnel should administer treatment prehospitally. The public should be urged further to make early contact in cases of chest pain.
Age Distribution↗
Respiratory rate as a prehospital triage tool in rural trauma.
BACKGROUND: Where trauma systems do not exist, such as in low-income countries, the aim of prehospital triage is identification of trauma victims with high priority for forward resuscitation. The present pilot study explored the accuracy of simple prehospital triage tools in the hands of nongraduate trauma care providers in the minefields of North Iraq and Cambodia. METHODS: Prehospital prediction of trauma death and major trauma victims (Injury Severity Score > 15) was studied in 737 adult patients with penetrating injuries and long evacuation times (mean, 6.1 hours). RESULTS: Both the respiratory rate and the full Physiologic Severity Score predicted trauma death with high accuracy (area under the curve for receiver-operating characteristic plots at 0.9) and significantly better than other physiologic indicators. The accuracy in major trauma victim identification was moderate for all physiologic indicators (area under the receiver-operating characteristic curve, 0.7-0.8). CONCLUSION: Respiratory rate > 25 breaths/min may be a useful triage tool for nongraduate trauma care providers where the scene is chaotic and evacuations long. Further studies on larger cohorts are necessary to validate the results.
Adolescent↗
Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia.
BACKGROUND: A five-year prospective study was conducted in North Iraq and Cambodia to test a model for rural prehospital trauma systems in low-income countries. RESULTS: From 1997 to 2001, 135 local paramedics and 5,200 lay First Responders were trained to provide in-field trauma care. The study population comprised 1,061 trauma victims with mean evacuation time 5.7 hours. The trauma mortality rate was reduced from pre-intervention level at 40% to 14.9% over the study period (95% CI for difference 17.2-33.0%). There was a reduction in trauma deaths from 23.9% in 1997 to 8.8% in 2001 (95% CI for difference 7.8-22.4%), and a corresponding significant improvement of treatment effect by year. The rate of infectious complications remained at 21.5 percent throughout the study period. CONCLUSION: Low-cost rural trauma systems have a significant impact on trauma mortality in low-income countries.
Adolescent↗
Land mine injuries: a study of 708 victims in North Iraq and Cambodia.
OBJECTIVE: The aim of this study was to explore the effect of low-cost prehospital trauma systems on trauma outcome in land mine victims and to study prehospital risk indicators for better triage of land mine injuries. METHODS: A 5-year prospective study of the effect of in-field advanced life support provided by local paramedics was conducted in mine-infested areas in North Iraq and Cambodia. RESULTS: After implementation of a rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001 (95% confidence interval for difference, 5.1%-23.6%). The mortality rate was significantly higher in fragmentation mine victims, 25.2%, as compared with blast mine victims, 5.7% (95% confidence interval for difference, 14.4%-24.6%). The severity of associated fragment injuries in patients with traumatic amputations is a solid risk predictor (area under the curve in receiver operating characteristics plots > 0.9). CONCLUSIONS: Low-cost prehospital trauma systems improve trauma outcome in land mine victims where prehospital transit times are high. The fragment wounds represent the main challenge for trauma care providers.
Adolescent↗
Chronic pain in land mine accident survivors in Cambodia and Kurdistan.
The aims of the study were to study chronic pain in land mine accident survivors, and to study the impact of trauma and trauma care parameters on chronic pain. The level of chronic pain was registered (patient-rated and by clinical examination) in 57 severely injured adult land mine accident survivors in Cambodia and Northern Iraq more than one year after the accident. As all study patients had been managed by a standardized trauma system, we could assess the impact of injury severity and primary trauma care on chronic pain. 64% of the study patients (n=36) had chronic pain syndromes (non-significant difference between the two countries). 68% of the amputees (19 out of 28) had phantom limb pain. Pre-injury trauma exposure, the severity of the actual trauma, and the quality of trauma care had no impact on end point chronic pain. In 85% of cases (n=48), the economic standing of the patients' family had deteriorated after the accident. Patient-rated loss of income correlated with the rate of chronic pain syndromes.
Adolescent↗
Preventing post-injury hypothermia during prolonged prehospital evacuation.
INTRODUCTION: Post-injury hypothermia is a risk predictor in trauma patients whose physiology is deranged. The aim of the present study was to examine the effect of simple, in-field, hypothermia prevention to victims of penetrating trauma during long prehospital evacuations. METHODS: A total of 170 consecutively injured landmine victims were included in a prospective, clinical study in Northern Iraq and Cambodia. Thirty patients were provided with systematic prehospital hypothermia prevention, and for 140 patients, no preventive measures were provided. RESULTS: The mean value for the time from injury to hospital admission was 6.6 hours (range: 0.2-72). The incidence of hypothermia (oral temperature < 36 degrees C) before prevention/rewarming was 21% (95% confidence interval: 15% to 28%). The Prevention Group had a statistically significant lower rate of hypothermia on hospital admission compared to the control group (95% confidence interval for difference: 6% to 24%). CONCLUSION: Simple, preventive, in-field measures help to prevent hypothermia during protracted evacuation, and should be part of the trauma care protocol in rural rescue systems.
Adolescent↗
Mortality in land-mine accidents in Iran.
OBJECTIVE: To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran. METHOD: Survey at rural clinics in mine-affected areas, and retrospective review of public patient records. RESULTS: A total of 36.4% of casualties from land-mines in the study area died during the period of 1989-1999. The mortality seems highest in those victims who were torso injured. CONCLUSION: The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.
Blast Injuries↗