In Norway, helicopter emergency medical services (HEMS) are dispatched for suspected cerebral stroke if intravenous thrombolysis may be administered within 4.5 hours of symptom onset, and it reduces time of transport by ≥30 minutes compared with basic emergency medical services (EMS). However, cerebral stroke presents with heterogeneous symptoms; therefore, identification by emergency dispatchers can be difficult. The primary outcome was the positive predictive value for stroke among patients with suspected stroke for whom HEMS was dispatched. Secondary outcomes included rates of prehospital interventions, quality indicator fulfillment, and rates of selected in-hospital interventions within time limits. We conducted a retrospective cohort study using aggregated prehospital and in-hospital data from an electronic patient journal. It included 161 primary missions from the HEMS base in Trondheim, where HEMS was deployed on the index criterion of cerebral stroke set by the Emergency Medical Coordination Center between 2022 and 2024. Of all primary missions, 14% (n = 162) were because of suspected stroke. A total of 75 patients (47%) were diagnosed with having stroke, whereas 12 (7%) were diagnosed with having transient ischemic attack. In 7% of cases, an advanced intervention that requires a physician was performed. A total of 40 patients (25%) received intravenous thrombolysis and/or endovascular thrombectomy. Stroke was confirmed in 47% of HEMS dispatches for suspected stroke. HEMS likely reduced transport time by ≥30 minutes for most patients, whereas prehospital advanced interventions were rarely performed. Further studies on index use and comparative studies of HEMS and EMS dispatches could help strengthen patient selection and optimize resource utilization.
Emergency resuscitative thoracotomy (ERT) is a crucial intervention employed in prehospital settings to address life-threatening conditions, such as cardiac tamponade, hemorrhage, and air embolism. Despite its critical nature, the efficacy of prehospital ERT in enhancing survival rates compared with in-hospital procedures remains controversial. This retrospective analysis was conducted using data from the Japanese Society for Aeromedical Services Registry between January 2020 and December 2022. After excluding nontraumatic cases, non-ERT cases, and records with missing data, 143 prehospital ERT cases were identified. The cohort was categorized into survivors (n = 3) and nonsurvivors (n = 140) based on patient outcomes. Comparative analyses were conducted on variables such as age, injury severity, time intervals, and transportation modalities using the Wilcoxon rank-sum test and Pearson's chi-square test, with the statistical significance set at P < .05. The overall survival rate after prehospital ERT was 2.1% (3 of 143). Only a few variables, such as hospital length of stay, showed statistically significant differences between the groups; most patient characteristics and prehospital time intervals did not. The patients who experienced cardiac arrest at the time of contact with the emergency medical service (EMS) contact had a survival rate of 0%, whereas those who arrived at the hospital with vital signs had the highest survival rate (11.1%). The presence of vital signs upon hospital arrival and the rapid initiation of intervention were identified as key factors influencing survival. These findings suggest that prehospital ERT provides limited survival benefits, with a 0% survival rate in cases of cardiac arrest at EMS contact. Therefore, further research is essential to refine the patient selection criteria and optimize ERT deployment to improve prehospital patient outcomes.
The Commission on Accreditation of Medical Transport Systems has used patients being admitted for less than 24 hours at the receiving facility as a surrogate marker for improper helicopter emergency medical services (HEMS) utilization, therefore triggering a review to determine proper HEMS utilization. Recent guidelines modified this to use discharge directly from the emergency department (ED) after transfer as a marker for inappropriate HEMS utilization. This study aimed to evaluate which metric is associated with better adherence to Wisconsin (WI) HEMS utilization criteria in adult trauma patients transported to the ED. This was a retrospective chart review of 1,520 transports by a midwestern HEMS service to a level 1 adult trauma center between January 1, 2013, and December 31, 2022. Charts with a disposition of discharge home, admission of less than 24 hours, or death in the ED were evaluated for adherence to WI HEMS utilization guideline criteria. A total of 287 patients met the inclusion criteria. Most patients were transported directly from the scene; 53% of transports met utilization criteria. Interfacility transports were more likely to meet utilization criteria than scene transports. Patients admitted for less than 24 hours were more likely to meet utilization criteria than patients discharged directly from the ED. This significance occurred for both scene and interfacility transports. Patients transported after a motor vehicle crash were less likely to have met utilization criteria. Patients admitted for less than 24 hours were more likely to have met WI HEMS utilization guidelines than patients discharged from the ED. The relatively low adherence rate to the WI HEMS utilization guidelines suggests that stricter guidelines may be necessary to reduce overtriaging in HEMS transport.
Helicopter Emergency Medical Services (HEMS) play a crucial role in providing timely emergency care, leading to improved patient outcomes. This study aimed to analyze HEMS time intervals in Iran through a systematic review and meta-analysis. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in various databases up to August 2025. Ten studies were included for quality assessment and meta-analysis using a random-effects model. Data analysis was performed using STATA 14 software. The meta-analysis revealed that the mean response time, on-scene time, and transport time for HEMS in Iran were 19.55 minutes, 10.46 minutes, and 14.63 minutes, respectively. The overall mean HEMS time was reported as 50.59 minutes. Meta-regression analysis revealed a decreasing trend in response and on-scene times over the years, whereas transport time and overall HEMS time exhibited an increasing trend. HEMS in Iran demonstrate acceptable operational times, but improvements in triage, fleet enhancement, and the establishment of a national HEMS registry are needed to enhance efficiency and evidence-based decision-making.
The timing of Emergency Medical Services (EMS) notification, crash scene arrival, and hospital arrival may impact motor vehicle fatalities. We examined EMS response time intervals over the past three decades, considering the effects of weather, vehicles involved, time of day, and location. We used the Fatal Accident Reporting System to compute and describe annual (1987-2020) EMS response time intervals. This included total time (i.e., crash-to-hospital), as well as the intervals between four key timepoints: crash, crash notification, crash scene arrival, and hospital arrival. We examined the proportion of fatal crashes with total intervals under 60 min (i.e., the "golden hour"), and where the crash arrival-to-hospital interval was under 30 min (the "beneficial timeframe"). Additionally, analyses were stratified by crash factors including weather (poor/clear) number of vehicles involved (single/multiple), time of day (early morning/rest of the day), and location (urban/rural). A total of 310,001 fatal crashes were analyzed. Between 1987-1994 total median response times ranged between 40 and 42 min. By 1999, intervals had increased to 45 min; elevated intervals were evident through 2009. By 2020, observed intervals had returned to 41 min. Paralleling this pattern, crashes with "golden hour" intervals decreased from 77.0% in 1987 to 72.4% in 2009 and increased to 78.0% by 2020. Similarly, crashes with a "beneficial timeframe" decreased from 60% in 1987 to 52% in 2009 and increased to 56.0% by 2020. The largest discrepancies for crash strata were evident for location: rural crash total response time intervals were 15-23 min longer than urban. From 1987-2020, the total time response interval following a fatal crash remained relatively stable. However, steady increases in intervals between crash notification and both crash scene and hospital arrival are evident. Future research should focus on approaches to reduce response time intervals.
An emerging strategy to alleviate healthcare system pressures are prehospital treat and discharge directives, allowing paramedics to manage patient care in the community without transporting to an emergency department (ED). In Ontario, Canada, three discharge directives apply to patients with resolved seizures, resolved hypoglycemia, and resolved supraventricular tachycardia. Our objective was to describe how these directives were utilized in practice and to characterize associated operational metrics and downstream ED utilization among eligible patients. We conducted a retrospective cohort study using paramedic records from southwestern Ontario between June 1, 2023, and November 15, 2024. All 9-1-1 calls were screened using objective criteria in the medical directives to identify patients who may have been eligible for paramedic discharge. Patient records were categorized into groups by directive, then classified by their call outcome (transported, discharged by paramedics, patient refusal of transport). Where established linkages existed, transported patient records were linked to their ED visits. We examined paramedic scene times and call durations across groups, and ED metrics of length of stay (LOS), wait time for physician assessment, visit outcome, and visit costs. Of 1,596 patients identified as potentially eligible for discharge, 1,085 (68.0%) were transported to an ED, 474 (29.7%) patients refused transport, and 35 (2.2%) were discharged by paramedics. Paramedic discharged patients had half the median call duration (45 minutes) of ED transported patients (87 minutes). Patients with hypoglycemia had a high rate of transport refusal (58.9%), while the cohort of patients with seizure had the highest rate of transport (72.0%). Among 494 patients with linked ED data, the mean ED LOS was 6 hours and 20 minutes. Most were discharged (70.2%) or left before completing care (13.4%). The average ED visit cost was $461 in Canadian dollars (not including physician billing), and the mean wait time for physician assessment exceeded 1.5 hours. Paramedic-initiated discharge was used infrequently, but cases in which it was applied were associated with shorter call durations and avoided subsequent ED utilization. These descriptive findings suggest potential operational advantages worthy of further evaluation, though additional research is needed to determine safety, and system-level impact.
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, mandates that individuals presenting with emergency medical conditions receive appropriate screening, stabilizing treatment, or transfer-regardless of their ability to pay or mode of transport. As EMTALA approaches its 40th anniversary, recent legal developments, including the Idaho and Moyle cases, have tested its federal preemption and implications for emergency medical transfers. This article evaluates evolving enforcement, regulatory shifts, and operational impacts on air medical services. It highlights compliance risks, reimbursement pressures, and best practices for air medical providers navigating a complex legal landscape. The analysis underscores EMTALA's enduring role in safeguarding emergency care and the need for coordinated legal and clinical strategies in air medical transport.
The Team Emergency Assessment Measure (TEAM) questionnaire is widely used to assess non-technical skills (NTS) in emergency care. An updated and culturally adapted version is needed to ensure continued relevance, particularly for Spanish-speaking professionals working in emergency care settings. To translate, culturally adapt, and validate the TEAM questionnaire for Spanish-speaking emergency teams in a high-fidelity simulated environment. A back-translation and cross-cultural adaptation process was conducted. Twelve Emergency Medical Services (EMS) professionals (nurses, physicians, and Emergency Medical Technicians (EMT)) participated in high-fidelity simulation scenarios. Two evaluators used the translated tool to assess team performance, generating 700 ratings. Psychometric analyses included internal consistency, exploratory factor analysis, inter-rater reliability, and Bland-Altman plots. The Spanish TEAM (s-TEAM) questionnaire showed acceptable psychometric performance in this pilot sample. Four factors explained 80.8% of the variance. Internal consistency was high (α and ω > 0.90). Item 6 showed poor performance; its removal improved reliability. Inter-rater agreement exceeded 80%, though some items had lower ICC and kappa values. The updated s-TEAM shows promising preliminary validity and reliability for assessing NTS in Spanish-speaking emergency teams under simulated conditions. Removing items 6 and 12 and using a standardised 1-10 scale may enhance precision and usability. However, these findings should be interpreted as preliminary pilot evidence, and further validation in real-world emergency settings is required before broader clinical implementation.
Management of the pediatric airway is a challenging procedure in prehospital emergency medicine. This retrospective study evaluates prehospital airway management in 920 pediatric patients in a German helicopter emergency medical service (HEMS) system from 2012 to 2021. Prehospital pediatric intubation was a rare event (0.2% of all missions). Good visualization of the glottis (Cormack-Lehane I or II) was possible in 96.3% of the intubations. The first-pass intubation success was 86.6%; all children could finally be intubated successfully. The use of muscle relaxants significantly improved first-pass success in prehospital emergency anesthesia (90.1% vs. 83.1%; P = .002). We recognized a low rate of the use of aids such as stylet, bougie, or video laryngoscopy. The use of video laryngoscopy increased over the years, but did not translate into a higher first-attempt success rate. When taking over children with an already managed airway, HEMS teams found tube malplacement in 8.4% of the cases in primary missions. In the analyzed data, pediatric airway management was on a comparable level with adult airway management. Nevertheless, room for improvement and a need for further studies were identified.
As third-year medical students transition into high-stakes, high-stress clinical environments like the emergency department (ED), they may experience significant personal trauma. However, little is known about how this trauma is experienced early in their training - specifically during the transition from preclinical to clinical learning environments. This study addresses that gap by exploring third-year medical students' experiences of trauma during the emergency medicine (EM) clerkship through the lens of Trauma-Informed Care (TIC) and identifies workplace factors and intersectional demographics influencing these experiences. This qualitative study used the critical incident technique to explore emotionally-significant events encountered by third-year medical students immediately after completing the EM clerkship as their first core clerkship at a single academic institution. We conducted a thematic analysis using the Substance Abuse and Mental Health Services Administration's six TIC principles. Data were triangulated with quantitative demographic data, and data saturation was confirmed through constant comparison and reflexive team discussions. Seventeen students participated, describing 19 critical incidents of trauma. The most common trauma types involved lack of peer support and lack of empowerment or voice. Intersectional factors such as race, gender, and age shaped both the type and nature of trauma. Clinical uncertainty, power differentials, and unprofessional behavior emerged as frequent triggers. Applying a trauma-informed framework to medical education reveals how structural and interpersonal factors contribute to student trauma when they transition to the clinical learning environment. These findings highlight opportunities for trauma-informed clerkship design and structured support to create safer, more inclusive learning spaces. Not applicable.
Emergency medicine (EM) residency curricula are designed to prepare future physicians for independent practice. Although the Accreditation Council for Graduate Medical Education requires that EM residents have prehospital experiences, very few programs augment this experience with a dedicated resident response vehicle. There are minimal data demonstrating the utility of such an approach. Our residency program staffs a dedicated response vehicle with a PGY-2/3 resident 24/7/365 to respond to high-acuity emergency medical services (EMS) calls. Additionally, from 0800 to 2300, the on-duty resident provides on-line medical control (OLMC) for the county. Each resident averages one 24-hour shift per 4-week EM block. The purpose of this study is to describe the prehospital educational experiences and curricular contributions that this program provides. We used a retrospective observational study design of administrative patient care records over a 5-year period. The primary outcomes were the number of unique encounters and patient experiences per resident per cohort year. The secondary outcomes included characterization of the prehospital experiences among all residents: physician role, patient age-group and sex, problem type, scene location, and procedures. Descriptive statistics were computed to quantify the number, type, and characteristics of the prehospital encounters. Ninety unique resident users were identified in the charting system. The mean number of encounters per resident was grouped by graduation year and spanned from 28.7 (SD 15) for 2018 to 79.2 (SD 49.2) for 2022, with a range of 2 to 222 encounters per resident documented. Over the study period, our residents managed 1313 out-of-hospital cardiac arrests (34 pediatric), 1048 refusals, 596 death pronouncements, 172 critical trauma patients, and answered 2053 complex OLMC consults. This study quantified the prehospital experiences of our senior EM residents with the addition of a physician response vehicle to our longitudinal EMS curriculum. This has allowed our residents to gain valuable first-hand exposure to out-of-hospital adult and pediatric cardiac arrests, refusals of care, altered mental status, and respiratory emergencies, in addition to prehospital scenarios not likely to be seen within the hospital walls, including motor vehicle collisions with entrapment and mass casualty incidents.
HIRAID is an evidence-informed emergency nursing framework developed to address critical safety and quality gaps in emergency care. It was trialled with 1300+ Australian nurses, the largest ever trial with emergency nurses. It was developed to standardize emergency nursing assessment and management, addressing longstanding variability in clinical practice and training. HIRAID has demonstrated reduced patient deterioration, enhanced documentation, better clinical handover, and improved patient experience across 130+ Australian emergency departments. It is now expanding into residential aged care and inpatient hospital settings. HIRAID is a nurse-led framework specifically designed to support the delivery of timely, high-quality care.
Survival rates for childhood cancer remain far lower in low- and middle-income countries (LMICs) compared to high-income countries (HICs). In Tanzania, challenges in cancer care for children are driven by shortages of trained providers, limited infrastructure, and constrained access to essential medications. This study evaluates pediatric oncology capacity and infrastructure in Northern Tanzania to identify system gaps and opportunities for improvement. A cross-sectional survey of capacity for pediatric cancer care was conducted at 25 hospitals across the Kilimanjaro, Arusha, Manyara, and Tanga regions in Tanzania. Facilities included health centers, district hospitals, regional hospitals, and one zonal referral hospital. Using a tool adapted from the International Society of Paediatric Oncology (SIOP) Global Mapping Survey, the World Health Organization Essential Medicines List, and the Global Initiative for Childhood Cancer, we collected data on hospital infrastructure from hospital leaders and staff. Key indicators included diagnostic imaging, pathology services, oncology workforce, medicine availability, treatment modalities, and cancer case volumes. Descriptive statistics were summarized using R. Of the facilities surveyed, only one hospital (Kilimanjaro Christian Medical Centre) had a dedicated pediatric oncology ward and subspecialized staff. Although all facilities reported access to basic imaging such as x-ray and ultrasound, advanced imaging modalities (CT, MRI, specialized imaging) were confined to higher-level hospitals. Only 1 out of 25 hospitals offered pathology and pediatric surgical services. Among 20 essential pediatric oncology medicines assessed, only dexamethasone was universally available. District hospitals, despite serving the largest pediatric catchment areas and recording the highest admissions for children, lacked dedicated pediatric oncology wards. Pediatric oncology services in Northern Tanzania are constrained by shortages in infrastructure, personnel, diagnostics, and medications. District hospitals have limited capacity to treat childhood cancer, resulting in critical delays in diagnosis and treatment. Strengthening infrastructure at the district level, creating efficient referral systems, and embedding pediatric oncology care into broader health systems may improve survival outcomes for children with cancer.
Family nursing in Japanese emergency and acute care settings is deeply influenced by cultural norms that emphasize familial involvement in patient care. However, institutional constraints often impede meaningful engagement, particularly in high-acuity and crisis contexts. The scoping review revealed that family nursing in emergency departments remains fragmented, primarily qualitative, and highly dependent on individual nurses' discretion. Postpandemic data indicated a decline in relational competencies, especially among senior nurses. To foster ethical, culturally responsive family nursing in emergency care, system-level investment is needed in structured protocols, measurable outcomes, interprofessional collaboration, and education that integrates emotional and ethical competencies.
Preoxygenation is a key component of prehospital emergency anesthesia (PHEA), reducing hypoxemia and increasing safe apnea time. Delayed sequence intubation (DSI) involves the use of sedation without blunting respiratory drive to facilitate optimization, primarily oxygenation, before paralytic administration and subsequent intubation in patients with agitation who are unable to tolerate preoxygenation. This scoping review explored the evidence supporting DSI in emergency and prehospital practice. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided scoping review was conducted. MEDLINE and Embase were searched from inception to May 5, 2025, for studies reporting DSI. Primary studies, case series, case reports, and guidelines involving adult or pediatric patients were included; reviews, editorials, and letters were excluded. Titles, abstracts, and full texts were independently screened by 2 reviewers, with disagreements resolved by a third. Fourteen studies met the inclusion criteria. Across these studies, 310 DSI cases were reported, including 140 performed prehospital by physician- and paramedic-led teams. Emergency department evidence suggests that DSI may reduce hypoxemia in agitated patients compared with rapid sequence intubation (RSI), with 1 randomized controlled trial reporting hypoxemia rates of 8% versus 35% (P = .001). Evidence specific to prehospital DSI was limited to retrospective studies, with no randomized controlled trials identified. Limited evidence suggests that DSI can be performed by teams already delivering PHEA using an RSI technique and may reduce hypoxemia in those patients unable to tolerate preoxygenation. Further prospective research directly comparing RSI and DSI techniques in the prehospital setting is required to inform future practice.
Health care workers are confronted with workplace violence daily. The US Bureau of Labor Statistics reported that, in 2018, 73% of all nonfatal injuries or illnesses involving health care workplace violence were from patients and/or family members. This quality improvement project aimed to decrease workplace violence using a behavioral emergency response team. During the project period, the behavioral emergency response team protocol was not activated. Analysis, reduction, and management of risk in health care settings are essential to help reduce and prevent adverse events and errors. A failure modes and effects analysis process was used to analyze the rationale for the lack of process activation. Failure modes and effects analysis findings suggest that although ED staff can recognize escalating behaviors from patients, 45% of surveyed staff (n = 9) were unaware of how to activate a behavioral emergency response team. Early recognition of escalating behaviors could possibly help prevent further violence from taking place in a health care setting. Therefore, it is important for staff members to quickly acknowledge behavioral cues to help reduce the risk of violence from happening. This highlights the importance of increased marketing to ensure that team members are aware of the protocols in place to help decrease opportunities for workplace violence once behavioral cues are recognized.
Air ambulance helicopters are a scarce and costly resource in New Zealand. Despite widespread use of the Advanced Medical Priority Dispatch System (AMPDS), no validated framework exists to determine which determinant codes are associated with helicopter tasking. This study aimed to examine whether specific AMPDS codes are associated with an increased likelihood of helicopter arrival at the scene in New Zealand. A retrospective observational study using all AMPDS-coded incidents recorded by the Emergency Ambulance Communications Centre from January 1, 2023, to December 31, 2024, was conducted. Exclusions included interhospital transfers, search and rescue events, direct air desk notifications, and nonpatient incidents. For each code, incident volume and helicopter arrivals at the scene were measured. Codes were classified as high volume (≥ 50 helicopter arrivals) or high yield (arrival ratio, ≤ 1:10). Among 1,161,169 AMPDS-coded incidents, 34,869 (3.0%) were reviewed by an air desk clinician and 7,688 (0.66%) resulted in a helicopter arrival. Thirty-seven codes generated ≥ 50 arrivals, accounting for 59.3% of helicopter responses but representing 440,781 incidents overall. An additional 102 codes had arrival ratios of ≤ 1:10, although most had low absolute volumes. Only 3 traffic-related codes (29D06, 29D02N, 29D02K) met both criteria, accounting for 823 incidents (0.07%) and 192 arrivals (2.5%). In contrast, 791 codes never produced a helicopter arrival, including 133 with > 100 incidents. AMPDS codes alone have limited discriminative capacity for helicopter tasking in New Zealand. A small subset of traffic-related codes demonstrated predictive value and may support more targeted referral pathways. Integrating selected high-yield codes with geospatial thresholds and availability of local critical care resources may streamline clinician review, reduce overtriage, and optimize deployment of scarce aeromedical assets.
The recreational use of cannabis is a significant (and growing) contemporary public health issue, confounded by the rapidly changing state and federal marijuana regulation and legislation. As of 2025, 24 states and the District of Columbia have legalized cannabis for medicinal and recreational use, and 39 of the 50 states have legalized it for medicinal use. With the increased use of recreational and medicinal marijuana, there has been an uptick in emergency department (ED) visits for cannabis-related illnesses, including gastrointestinal, cardiac, and mental health disorders. Nausea and vomiting, which are the hallmarks of cannabinoid hyperemesis syndrome (CHS), have been reported as the most common reasons for cannabis-related ED visits in nationwide ED data set analysis. Emergency department staff need to be familiar with CHS, its presentation, pathophysiology, and treatments to quickly recognize, diagnose, and triage/treat patients suffering from this acute cannabis-related GI illness.
Falls are a leading cause of emergency department (ED) visits among older adults, often resulting in fractures. Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic tool for emergency nurse practitioners (ENPs), offering rapid, radiation-free evaluation of musculoskeletal injuries. This article examines the effectiveness of POCUS in detecting fractures, with evidence demonstrating high sensitivity and specificity, particularly for long-bone injuries. A case study of a patient with a humeral fracture highlights the utility of POCUS in diagnosis and expedited orthopedic referral. The article also discusses ultrasound physics, bone imaging techniques, and transducer selection for musculoskeletal assessments. Beyond clinical accuracy, POCUS use is associated with reduced ED length of stay and healthcare costs. While operator-dependent, structured training models are expanding ENP proficiency in POCUS. Integrating this modality into ED practice enhances timely triage and improves patient outcomes, particularly in resource-limited or high volume settings.
Patient-centered care (PCC) in primary health care emergency settings in low and middle-income countries centers on trusting patient-provider relationships and treating individuals with dignity, while involving them in all decisions. Grounded in the WHO definition of primary healthcare centers (PHCs), it promotes early, close-to-home emergency responses that reduce delays and travel barriers, and it requires a whole-of-society approach that engages communities, leaders, and networks. Adapting PCC to local cultures, including traditional practices and communication styles, strengthens care when resources are limited. Trust is built through honest discussions of constraints and family involvement.