SJH ED goes to ICEM 2023

Authors: Emma Philp and Deepankar Datta

Both of us are looking forward to being at ICEM 2023, the 22nd International Conference on Emergency Medicine, which is taking place in Amsterdam this month.

Emma is one of our Advanced Nurse Practitioners at St John's Hospital Emergency Department. She’s a lynchpin in the staffing of our department, and is currently in the process of credentialing as an RCEM ACP. Locally she’s a beacon for what an ANP can achieve.

I’m glad we had a successful poster submission for ICEM 2023: there’s a few benefits to this. It’s highlighted the role of Emma in our department and has convinced our bosses to sponsor Emma to go. It raises the profile of the ANP role, and ANP training, locally. And it gives Emma experience of doing research and going to conferences. So wins all round.

On a personal basis, it's been years since I've been to a conference, so I'm looking forward to learning lots and catching up with fellow emergency medicine specialists from around the world.

We wanted to write a bit more about our poster, “Women’s experiences and perspectives during early pregnancy miscarriage in the emergency department: a literature review”, than can be displayed at ICEM – and this is a shout out to the beneficial technology of QR codes.

If you want access to an electronic version of the poster, click the image below:

So here’s Emma’s thoughts on the work:

The topic for this literature review was chosen after I reflected on some of the clinical cases I had seen in the ED. One particularly memorable patient who presented with mild abdominal cramping and some PV bleeding in early pregnancy waited 2hrs to be seen by a care provider. When she was reviewed she was noted to have a biscuit tin with her. This biscuit tin contained the products she had passed which could be easily identified. However no one had noted the significance of the biscuit tin, and she had sat in the busy waiting room for 2 hours with this on the seat beside her. The emotions this patient must have been feeling were hugely significant, however we failed to recognise this. I felt there was room for improvements in the care we deliver to this patient group, and so the need for this topic review.

The initial search for studies to be included in this extended literature review involved a search of MEDLINE, CINAHL and PYSCHINFO databases which produced 13,707 published articles. These were narrowed down to 6 articles using strict inclusion and exclusion criteria which can be seen in the PRISMA chart below.

The CASP (Critical Appraisal Skills Programme 2018) tool Qualitative Checklist was chosen to appraise the 6 studies to evaluate the quality and value of the published research. Of the 6 studies, 2 were deemed high quality and the remaining 4 were good quality. None of the studies were considered to score low/weak and therefore all 6 studies were included in the literature review.

The diagram below is a summary of the themes identified within the literature, which I summarised into four key areas:

1. the ED environment

2. poor communication and psycho-social care

3. lack of follow-up care

4. lack of information

Literature Review

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Thanks again for looking at the poster and reading further into what was done. If you have any questions, please don’t hesitate to get in touch with Emma or myself.

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Thanks

Thanks to all our colleagues at St John's ED as well as our wider colleagues within Edinburgh Emergency Medicine and NHS Lothian. Specific thanks to AL for helping supervise the research; RA (the boss!) for supporting Emma for doing this work; the wider NHSL team for being supportive of Emma’s ANP role; AS, MM and BW for proof-reading; and DM for helping to get this blog posted.

robin mitchell fellowship: iceland part 4

An Insight into Iceland’s Emergency Medicine and Pre-Hospital Care Systems

Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery

The last part of my Fellowship was scheduled to take place in the north of Iceland in Akureyri, the largest town outside the populous south west of the country and only 100km away from the Arctic Circle. From Reykjavík it’s a 400km drive on a stretch of Route 1, the ring road which runs all the way round the island. As always here, there is no shortage of stunning mountainous and coastal scenery to take in on the way!

Once I had arrived, my first stop was the small airport on the edge of town, where the air ambulance service is based. Due to Iceland’s sparse population, long transport distances and numerous small airports, the majority of aeromedical operations in Iceland is accomplished using fixed-wing aircraft. The Icelandic government contracts this service out to the airline Mýflug, based in Akureyri. Named after a local lake, the airline was established in 1985 and conducts air ambulance flights all over Iceland as well as international destinations including Greenland, Scandinavia and the UK. The airline flies around 700-800 air ambulance flights per year, around one third of which require a doctor on board.

I would be spending my week here on-call with Dr Barbara Hess, a Consultant Anaesthetist and Flight Doctor based in Akureyri. She began by showing me around the aircraft and its hangar, as well as the medical kit on board. The aircraft used for the air ambulance flights are two specially configured Beechcraft Kingair 200s, both on constant standby at Akureyri airport. Each aircraft has room for two patient stretchers, monitors and kit bags for medical equipment and medications. Flight times within Iceland are generally in the range of 30-60 minutes.

There is an air ambulance crew on call 24 hours a day, consisting of a captain, co-pilot, paramedic and doctor. When there is an activation, the team will generally respond from home (unless already on a mission), but as Akureyri is a small town and traffic is generally light, travel times to the airport are usually only a few minutes. There are currently seven flight doctors on the rota, with base specialties of EM, anaesthetics and GP. The doctors generally work stretches of 48-72 hours on call and it appeared that this was integrated and supported fairly well alongside their hospital work.

Requests for the air ambulance are usually made by a rural doctor or paramedic via the emergency services dispatch room in Reykjavík, at which point a triage category is allocated. The on call flight doctor and paramedic then receive a notification on their mobile phone that there has been an air ambulance request. After this there they will usually contact the requesting clinician by phone to obtain further information and give advice if required.

It was a busy few days on the air ambulance, with one of the days involving eight flights to all corners of the country. Landing at some of Iceland’s numerous small remote towns where medical facilities are limited, it was easy to see how vital the air ambulance was in connecting patients with the rest of the country’s health service. The patients we dealt with on our activations had a wide age range, from a 21 month old to patients in their eighties. The clinical issues were also varied, including STEMI, fractures, pulmonary oedema, seizures, psychiatric problems and post-operative complications. Most patients were being transferred from remote towns to Reykjavík or Akureyri for further care, but there were also patients being transferred back to their local community hospital for step down care (this was generally arranged opportunistically when the air ambulance was available). 

It struck me that the whole process was very smoothly co-ordinated. After activation the aircraft was always waiting on the tarmac in Akureyri by the time the flight team arrived, and the pilots would have us airborne with minimal fuss in just a few minutes. On landing at the destination airport, there would always be an ambulance waiting to take the patient on the last leg of their hospital transfer, as well as an aircraft fuelling truck on standby. The loading and offloading of patients from the aircraft was also efficient and well-practised, with all members of the team involved. I could appreciate the rewards of working in this small close-knit team – not only through enabling unwell patients in remote and rural areas to access timely medical care, but also the regular added bonus of spectacular views of Iceland from the air! 

In between air ambulance calls, I also managed to spend some time in the emergency department in Akureyri Hospital, which enjoys a scenic location looking over the fjord Eyjafjörður. This is Iceland’s second largest hospital and is the main centre for specialised services in the north and east of the country. There are wards on site for general medicine, paediatrics, psychiatry, surgery and maternity, as well as a five bed critical care unit, operating theatres and the emergency department. CT and MRI are both available during day time hours. 

The emergency department sees around 18000 patients per year, although like many of Iceland’s rural health care facilities, they face the issue of significant attendance surges related to tourism. There are currently four consultant level doctors working in the department (3 full time equivalent), but this only allows for senior doctor presence during day time hours on week days. There is a plan to recruit a further senior doctor, but like some rural hospitals in Scotland, achieving suitable recruitment to these posts can be a challenge. In addition the department usually has an EM trainee doing a six month post (usually at ST1 level) and a small number of junior doctors and final year medical students rotating through. Out of hours medical staffing is generally provided by a combination of the department’s junior grades and the junior doctors covering inpatient medicine and surgery.

Although small, the department was well laid out along a single corridor, with a single large resus room opening directly into the ambulance garage. As in Reykjavík, there was no shortage of computers, work spaces and relaxation areas for doctors and nurses, and all equipment was well stocked and meticulously organised. There was plenty of clinical variety while I was there, with the day of the ED-led fracture and review clinic being especially busy. Fractures are a particularly common presentations here, particularly over the long snowy winters and given Akureyri has become a popular destination for activities like skiing and mountain biking. After a great week in the north and just a couple of days left of my time in Iceland, it was time to head back to the capital.

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Once back in Reykjavík I took the opportunity to do a final shift in Landspítali’s emergency department, which I realised as I was leaving, was also my last shift as an EM trainee! I have certainly learned a lot from being immersed in the health care system here and it has struck me that our respective departments and trainees could gain a lot from increased collaboration. I hope to maintain the link that the Robin Mitchell Fellowship has helped establish, by setting up the opportunity for other Edinburgh EM doctors to come here in future, as well as for Icelandic EM trainees to do some of their training in Edinburgh. Watch this space!

I feel fortunate to have gained such an in-depth perspective of how Iceland meets the clinical and logistical challenges of pre-hospital care, as well as how this may evolve over the coming years. I am also grateful of how incredibly welcoming, friendly and accommodating everyone has been during my time here. Reflecting on the last five weeks, it has undoubtedly been a highlight of my time as a doctor in training and an experience I will continue to draw upon for many years to come.

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I would like to extend my gratitude to the Robin Mitchell Fellowship Trustees for their support in making this experience possible. A special thanks go to my supervisors in Reykjavík and Edinburgh respectively, Dr Hjalti Már Björnsson and Professor Richard Lyon, as well as to the many others who have been instrumental in making this Fellowship a success: Dr Viðar Magnusson, Dr Barbara Hess, Dr Mikael Mikaelsson, Dr Jón Pálmi Óskarsson, Dr Zoe Rochford and Dr Ármann Jonsson. Lastly, thank you to all the excellent and helpful staff in the emergency departments, ambulance and aeromedical bases I visited. I look forward to visiting again soon.

Robin Mitchell Fellowship: Iceland Part 3

An Insight into Iceland’s Emergency Medicine and Pre-Hospital Care Systems

Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery

This week began with an opportunity I couldn’t pass up. The Icelandic Coast Guard had scheduled a helicopter mission to the far east of the country in order to undertake boat and water rescue exercises with one of the coast guard vessels. I was asked if I’d like to go along as the doctor just in case anything happened(!) The journey was one I won’t forget – a 1000km round trip across the centre of the country, passing over breathtaking scenes of glaciers, mountains, canyons, rivers and black lava fields. 

After re-fuelling at a small airport in a town called Egilsstaðir, we made our rendezvous with the coast guard vessel in the waters off the east coast. The crew ran through a series of live winch rescue drills, involving casualties from a life boat and open water, whilst the pilots skilfully maintained position just above the boat. We had a good day for it, with few clouds and moderate winds buffeting the helicopter. As I’m sure you can imagine, the Icelandic weather is not always this favourable – the coast guard maintain preparedness to undertake missions across the country 24 hours a day and in almost all weathers. During winching activity, where the side door of the helicopter was open, the crew switched to largely non-verbal and hand gesture-based communication due to the noise levels. It was clear that there was an innate understanding between crew and that these were well drilled activities, essential in high pressure but low volume rescue work. I enjoyed another stunning flight home and felt I’d had a great insight into some of the challenges involved in the Icelandic Coast Guard’s search and rescue operations. 

I spent the remainder of the week back on terra firma with Reykjavík’s ambulance service. Each day began at 0720 in the emergency services headquarters with a crew briefing and handover, followed by kit and vehicle checks. There are four ambulance bases in the Reykjavík area, each shared with the fire service. The central station where I was based also houses police and coast guard operations. During the week, I had the chance to tour all four of the bases and was introduced to the teams working in each. Once again, there was an excellent standard of facilities available to staff. All bases were kitted out with a full gym, sauna, comfortable sleeping rooms and staff living areas, well-equipped kitchens and a dining room where a healthy free meal was provided at lunchtime. We could certainly learn a thing or two about staff wellbeing here and I could see why they were keen to show me around!

The central emergency services base in Reykjavík also houses Iceland’s only emergency call handling and dispatch facility. I was able to spend some time with the staff in this facility, who manage all emergency service calls in the country. A notable positive of the co-location of the emergency service in this base is that the police service are right next door to the dispatch room, which helps with planning a response to incidents, particularly where a multi-agency response may be required. All emergency calls (made by dialling 112 in Iceland) are initially taken by a non-clinical call handler, of whom there are generally two or three working at any one time. In a similar fashion to ambulance calls in Scotland, they work with a script of questions, quickly establishing the clinical problem, the location of the caller and assigning a priority to the call. They are also able to request an ambulance at an early point in the call for immediately life threatening issues. Calls then appear on the screen of the dispatcher across the room (also non-clinical), of whom there are generally one or two working at any one time. They are able to activate or refine the emergency service response within a few mouse clicks, and can directly dispatch all emergency services from police through to fixed wing air ambulance. As touched on previously, they are not able to directly dispatch the Icelandic Coast Guard helicopter – this is generally done following a conversation with their team first. The system in place for categorising ambulance calls according to priority is similar to the one in use by the Scottish Ambulance Service (SAS). There have been recent efforts in Iceland to further optimise call prioritisation, with one of the local EM consultants involved in revising some of the scripts used by the call handlers.

Like Reykjavík’s emergency department, the integrated dispatch centre was operating with a custom made IT system, developed by one of the local ambulance staff. It appeared to be very user friendly, using computer-aided dispatch, satellite-based emergency service vehicle locating and detailed country-wide mapping data to facilitate optimal dispatch actions. For example, dispatchers are able to bring up surveillance camera feeds to give information about road conditions or a traffic accident to the responding teams. They are also able to remotely open certain gates on rural roads to allow response vehicles to pass! In rural areas where ambulance coverage is limited, they can task local GPs or members of the public to certain incidents and have a direct communication link to the small medical huts which dot the remotest corners of the country. To help prepare GPs for this aspect of their role, a specific course focused on pre-hospital care and rural emergencies has been devised and run by anaesthetics and emergency medicine physicians in Reykjavík. There is as yet no organisational equivalent to BASICS Scotland, which works in conjunction with SAS and The Sandpiper Trust to equip volunteer doctors, nurses and paramedics to act as first responders in rural areas of Scotland. 

During the week, I rode along in one of the ambulances tasked to higher triage category calls, staffed with an EMT and paramedic team. There are generally two ambulances operating at each of Reykjavík’s bases during the day – one for higher priority calls staffed with a paramedic and an experienced EMT team and one for lower priority calls staffed with a more junior EMT team. The scope of practice and autonomy of EMTs and paramedics here increases with grade and has broad equivalence to our own pre-hospital services, albeit with a few differences with job titles and available kit and medications. 

The patients we saw had clinical problems spanning a broad and familiar range including: palpitations, breathlessness, unresponsiveness, seizure, chest pain and musculoskeletal injuries. There was good co-ordination on display between ambulance crews and hospital staff – crews would generally pre-alert the nurse in charge of the relevant receiving clinical area by phone, allowing cubicle space to be organised and staff to be allocated in time for arrival. As well as providing a primary response, we also facilitated the hospital transfer of patients received from the fixed wing air ambulance servicing the rural parts of the country. I will talk more about this in Part 4. I found these shifts really valuable in giving a better appreciation of the pre-hospital phase of patient care here, but also through the opportunity for shared learning across our disciplines, which I think there is room for more of both here and at home.

Notable here is the wide range of additional training and roles available to EMTs and paramedics. Most of them are also fully trained in fire rescue, something they all seemed to value in providing added variety and job satisfaction. Furthermore, there are various additional specialised emergency service teams which paramedics are able to join and train for. One of these is the water rescue team, which recruits from within the paramedic team. Initial training for this is two months full time, followed by regular refresher training once on the job. The water rescue equipment is housed in a separate unit in the emergency services headquarters and includes a specialised ambulance with diving equipment, a rescue boat and equipment for ice rescue. Each member of the team has their own personal kit, which is checked and rotated daily and maintained in a state of readiness for a call out. 

There is also a specialised mountain rescue team within the ambulance service, the equipment for which is housed at one of the other stations I visited in the Reykjavík area. The kit available includes a specialised ambulance, all terrain quad bikes and equipment for mountain and snow rescue. In addition to this there is a specialised team and large dedicated response vehicle tasked to building collapses, the threat of which arises from the earthquake and volcanic activity in Iceland. One of the paramedics I worked with also serves on the specialised tactical response team, which requires him to train and dispatch alongside the police tactical team to respond to firearms incidents and terrorist attacks. As I observed in Selfoss last week, morale and job satisfaction amongst the Reykjavík paramedics was high and I could understand why!

This has been another great week and has really helped in piecing together how the pre-hospital systems operate here and where they are headed. Thank you to all the Reykjavík ambulance staff for making me welcome and part of the team, with a special thanks to the paramedics Helgi, Birkir, Christian and Gunnar.

Robin Mitchell Fellowship: Iceland Part 2

An insight into Iceland’s Emergency Medicine and Pre-Hospital Care systems

Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery

This Fellowship has allowed me to obtain a timely insight into Iceland’s pre-hospital care system, which is undergoing development at the same time that Scotland’s trauma and pre-hospital care systems continue to expand and develop. Like in Scotland, the isolated communities, challenging geography and harsh weather conditions of Iceland mean that a robust pre-hospital and retrieval network is a vital component of the heath service.

The second week of my time in Iceland began with a couple of days working alongside a paramedic team in Selfoss, a small town around an hour’s drive east of Reykjavík through some lovely mountainous scenery. The day began with a paramedic handover in a large shared emergency services base, which houses fire, ambulance, police and search and rescue operations. Owing to the relatively small population and the service demands in Iceland, it is common that emergency services share headquarters. This lends a number of advantages including the development of close working relationships and good understanding between personnel from different agencies, as well as reducing overhead costs.

Before attending to our first call out, I had a chance to have a tour of the base and gain familiarity with the vehicles and equipment in use, thanks to Bergur, an Emergency Medical Technician (EMT). Selfoss has two ambulances, both used for all levels of call out priority. They are fitted in a similar configuration to ours, with a few kit differences. Portable ventilators, advanced airway equipment including a video laryngoscope and intubation drugs are carried. This is principally due to the remoteness of some of the jobs, long transfer distances and limited medical cover available locally, although the need for pre-hospital intubation is infrequent. They also carry IV fentanyl and IV ketamine, the latter of which is often used for analgesia and is the go-to pre-hospital anaesthesia drug. 

There was an impressive standard of facilities available within the emergency services headquarters (this turned out to be a recurring theme!). There was a big staff room and kitchen with barbeque-equipped balcony looking over the River Ölfusá, numerous comfortable sleeping rooms, in addition to a fully equipped gym and sauna! The staff were clearly well looked after and morale was high. Outside of clinical and general duties, staff were encouraged to relax during downtime. I got to see their multi-agency major incident and conferencing room just before we headed out on a range of calls. The majority of patients were taken to the small hospital in Selfoss, with one requiring transfer to Reykjavík.

Owing to the long transfer distances in this rural and sparsely populated part of the country, paramedics here need to be fairly autonomous and are sometimes called to assist with unwell patients in the local community hospital, which often has only junior medical cover. Where required, paramedics can also call for medical support in pre-hospital decision making. However, some of these situations may be out of the comfort zone of the local rural GP or community hospital junior doctor, so this an area which has been proposed for development, which I will touch on later. Another current issue is in relation to transitioning the paramedic working pattern away from their traditional 12-hour shifts to 8-hour shifts. This initiative has been introduced at a governmental level and there appeared to be mixed opinions about it, particularly in relation to work-life balance.

The training structure and educational opportunities for paramedics in Iceland differ somewhat to our own. Most paramedics initially undergo training to basic EMT, then intermediate EMT level in Iceland. To be certified to paramedic level however, trainees must currently study abroad. This is usually in the US, where a full-time paramedic diploma is generally 10 months in duration from intermediate EMT level. Some also go to the UK or Norway, where the training is longer but results in a bachelors degree. A full paramedic qualification in Iceland is in development but has not yet implemented. 

Next week, my insight into Iceland’s ambulance system will continue when I spend time with the paramedics in Reykjavík, as well as learning about the call handling and dispatch system. A big thanks to everyone in Selfoss for making me welcome.

After this it was back to Reykjavik for an aeromedical weekend on call with the National Medical Director for Pre-Hospital Emergency Services, Dr Viðar Magnusson. This began at the headquarters of the Icelandic Coast Guard, whose hangar houses three big Eurocopter 225 Super Puma helicopters. In Icelandic fashion, these aircraft serve multiple roles, including coast guard, search and rescue and aeromedical operations, as well as civilian activities. The Coast Guard helicopter crew also operate in multiple roles – I observed the navigators and mechanics also operating as winchmen and found that all crew were trained to EMT level and able to provide support to the doctor on board. 

Iceland is sparsely populated, with challenging terrain and in many places, limited road access, making the Coast Guard helicopters invaluable for certain time critical pre-hospital and retrieval work. Activations can be made by rural doctors or paramedics, either through a direct conversation with the Coast Guard helicopter doctor or via the dispatch desk operator in Reykjavík. Given the centralisation of tertiary care and the numerous small airports dotted around the country, the other key component of aeromedical operations in Iceland is fixed-wing aircraft, which I will talk more about in Part 4. At present, there are in the region of 800 fixed-wing missions and 130-160 helicopter missions per year nationally.

After being kitted out with a flight suit, boots and helmet for the days ahead, I was given a rundown of the relevant helicopter essentials by the Chief Technician, Jon (namely how to operate the seat belts, communication system and how to get out of the side windows!). I then became familiarised with the medical kit that would be on board. There were kit bags for drugs, airway and trauma equipment, a portable monitor, a Lucas mechanical CPR device, a video laryngoscope and a portable ultrasound device. Blood products are not carried on board the helicopter at present. Should this be required, the police are requested to bring blood to the scene, which can have an impact on the promptness of administration.

Although impressive aircraft capable of flying in adverse weather conditions and carrying multiple passengers or patients, the 225s are not specifically designed and configured for medical use. This results in a few ergonomic issues for medical teams to deal with. These include the loading and securing of patient trolleys, optimal placement of monitoring equipment and the ease of access to medical kit bags, which are stowed behind a removable panel at the rear of the aircraft.

Next, I attended a pre-mission brief, where the pilots, navigator, winchman (in this case also the Chief Technician) and medical staff gather to discuss flight timings, routing, weather, potential hazards and contingency plans. I found out that the first mission for the day involved participating in a simulation being filmed for a documentary about the care of stroke patients in Iceland! This involved us flying to pick up our patient around 100km away before taking them to hospital in Reykjavík, during which several photographers were filming every stage of the patient journey and capturing some dramatic action shots of the crew. I found out that this would later be aired on Icelandic TV, so apologies in advance for any terrible acting or looking like a spare part!

Our medical activations included a capsized boat in a remote lake in the Highlands region (fortunately the occupants had managed to return to shore when we arrived on scene), and a drowning-related cardiac arrest (the patient survived, largely thanks to bystander CPR). Due to the recent downturn in tourism, the demand on Iceland’s aeromedical service has been relatively low, but this is expected to increase again soon. The Coast Guard helicopter was also tasked with transporting some scientists to the currently erupting Fagradalsfjall Volcano on the Reykjanes Peninsula in south west Iceland. I was able to ride along, for which I’m very grateful as we ended up flying over an otherworldly scene of black lava flows and venting gases, before deftly landing on a small rocky hilltop in the middle of all this. An experience I will never forget!

It was interesting to hear about some of the plans and aspirations for Iceland’s pre-hospital services from Dr Magnusson. These are all driven by a central aim of improving the overall quality and timeliness of pre-hospital care, as well as the equality of access to emergency and critical care for patients living in the remote areas of the country. A key part of this is the implementation of a national helicopter emergency medical service (HEMS), together with a dedicated helicopter. As one would expect, this is no small feat, requiring commitment from government and the wider health service for funding and support. In addition to this is the need for more pre-hospital trained medical staff able to balance pre-hospital work with other professional commitments, alongside the challenges of maintaining competencies in relatively low volume service. 

One of the issues facing the service at present is whether to have staff stationed in the Coast Guard base during their shifts. Currently, crews are on-call from home, meaning that if there is an activation, the pilots, mechanic, navigator, winchman, doctor and ground staff all make their way to the base. As Reykjavik is a fairly compact city, travel times are not long, but this does inevitably lead to a delay in getting airborne and on the way to a patient. The current time from activation to take off is typically around 40 minutes. There was some discussion around this following one of our activations, where it would have been desirable to minimise response time. It seems likely that the service will transition to having on-call staff stationed in the base during their shifts, but this will of course require additional financial support from the government, at a time when there are other competing health care developments.

One of the other areas to be addressed is the viability of re-distributing Iceland’s centralised helicopter resources, in order to improve medical responses in more remote areas. Currently all the Coast Guard helicopters are based in Reykjavík. One solution to improve response times and access would be have the available aircraft distributed evenly across the country (in a similar fashion to Scotland’s Emergency Medical Retrieval Service). This of course throws up issues of cost, staffing and infrastructure, with no clear and easy solutions. It is recognised that telemedicine will play an increasing role in providing decision support to remote medical staff in Iceland, although a system for this and who will staff it has not yet been determined.

An ongoing area of development has been the standardisation of Icelandic pre-hospital care through the implementation of protocols for drugs and procedures. In addition to this, a new electronic tablet-based paramedic documentation system is being developed by one of the EMT staff (the existing system is still paper-based). It is hoped that this will be much more user friendly and will assist with data capture. Another very recent development has been the addition of a response car in the Reykjavík area. Although not yet formally in service, it is envisaged this may be used by an advanced paramedic or doctor to provide pre-hospital support to paramedic crews during more challenging scenarios.

After a really interesting and memorable few days, I’m looking forward to the coming week, where I will be spending more time on the Coast Guard helicopter and with Reykjavík’s ambulance service.

Robin Mitchell Fellowship: A visit to Iceland

An insight into Iceland’s Emergency Medicine and Pre-Hospital Care systems

Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery

I have been very fortunate to be able to spend the final few weeks of my emergency medicine training in Iceland, thanks to the Robin Mitchell Fellowship. I was awarded the Fellowship last year, giving me an invaluable opportunity to explore Iceland’s emergency medicine (EM) and pre-hospital care systems. I hope you enjoy reading about my observations, experiences and reflections during this unforgettable attachment.

The Robin Mitchell Fellowship was set up in memory of Dr Robin Mitchell, an Edinburgh-trained EM physician, who died from pancreatic cancer in 2010. Outstanding as a clinician, educator and leader, Dr Mitchell had an influential and accomplished career in EM and pre-hospital care both in Scotland and New Zealand. For the last decade, The Robin Mitchell Fellowship has been awarded biennially to one EM trainee in Scotland in order to pursue a 4-6 week placement in an alternative environment, with the aim of advancing their clinical experience and expertise. 

The idea to travel to Iceland for the Robin Mitchell Fellowship was sparked following my brief insight into the county’s EM and pre-hospital systems during a visit in 2019. I couldn’t wait to come back and it was clear that I could learn a lot from a longer clinical placement and comparison of our respective systems. 

Iceland is an island nation situated just south of the Arctic Circle. It is the most sparsely populated country in Europe, with an area 1.3 times the size of Scotland, but home to only 360000 inhabitants, over 60% of which live in the capital Reykjavik. Perhaps Iceland’s most striking features are its stunning landscapes and abundant natural wonders, ranging through volcanoes, waterfalls, geysers, mountain ranges, fjords, hot springs and large areas of uninhabited desolation.   

Iceland and Scotland share a number of challenges in achieving equality of access to emergency care, including harsh, variable weather conditions, mountainous terrain and isolated rural populations. We also face similar EM-specific issues with increasing complex elderly presentations, overcrowding and exit block, as well as balancing training and service provision.

The health care system in Iceland has a structure similar to other Nordic countries, with the majority of services provided by the government. Private clinics also provide a significant proportion of patient care, but this is mostly funded by a government-run universal health insurance program.

Although Iceland has a medical school since 1876, opportunities for postgraduate specialty training have been relatively limited, with the majority of Icelandic physicians having gone abroad for their specialty training, mainly in other Nordic countries but also in the US, the UK and other countries. Most Icelandic doctors trained abroad move back home to practice, resulting in a system which benefits from a wide range of experience and approaches. Among the Nordic nations, Iceland was the earliest adopter of EM as a specialty, where the first emergency physician was licensed in 1992.  

Since then, EM training in Iceland has undergone a hard fought process of evolution. A key step in growing the specialty was the creation of a two-year residency program in 2002, based on a curriculum produced by the Icelandic Society for Emergency Medicine. This training program has since been redeveloped, with the Icelandic Directorate of Health recently approving a six-year EM training programme based on the Royal College of Emergency Medicine curriculum and examinations. All but 6 months of this programme can be completed in Iceland. There are currently 13 core EM trainees, 5 higher specialty trainees and 18 consultants (14 FTE) in the country.

EM trainees continue to be encouraged to do part of their training abroad, as this is felt to be an important component of becoming a fully trained specialist. My attachment in Iceland also presents an opportunity to establish a link between our respective departments and set up a regular exchange of trainees, thereby enriching future EM training both in Scotland and Iceland. I look forward to working on this once I am back home.

After an uncertain wait, the recent travel restrictions fortunately relaxed just in time for my attachment to go ahead in June/July 2021. I arrived in Reykjavik after an eerily quiet air travel experience and spent a bit of time getting my bearings before meeting some of the emergency department staff who would be my colleagues over the next few weeks. I made the most of the good weather that weekend by running some of the picturesque forest trails just outside the city. Visiting during the short Icelandic summer also gave a chance to experience the midnight sun, which takes a bit of getting used to!

My clinical attachment began with a few shifts in the emergency department (ED) at Landspítali, Iceland’s National University Teaching Hospital. Located in the centre of Reykjavik, it is Iceland’s main healthcare facility, with around 700 beds. It operates a wide range of clinical services and is where 70% of Iceland’s children are born. Landspítali’s ED sees around 70000 attendances per year and is split across two floors. The ground floor comprises two cubicle areas for major presentations (A for higher acuity and B for lower acuity), as well as four interconnected resuscitation bays, two specialty rooms and an eight-bed clinical decision unit. The upper floor is used for minor adult and paediatric trauma presentations, with a separate city hospital site taking medical paediatric presentations.

During day time hours each floor of the ED generally has one consultant and often a HST or core trainee in EM, in addition to a small number of junior doctors and senior medical students. There were fewer doctors on shift than we are accustomed to, but this was balanced with plenty of nursing and support staff. Reflective of Icelandic society in general, the ED working environment was informal, with everyone on first name terms and no role-specific uniforms (which I found tricky to begin with). Specialty referrals were fairly informal, with some specialties like cardiology often coming to see patients on the basis of a patient being marked for cardiology input on the IT system, rather than requiring a phone referral. The ED staff had a comfortable and spacious staff room, well-stocked with fresh fruit and other food, as well as the ever present high-end free coffee machine!

During my shifts I felt very welcome and able to easily integrate as a registrar, despite very limited Icelandic. This was considerably helped by being paired with a final year medical student scheduled to do a “scribe shift”. During these, the medical student accompanies a senior doctor with a portable computer, doing all the documentation and ordering of tests in real time. I found it a very efficient way to work and was able to go from patient to patient relatively seamlessly. It also provided an opportunity to deliver ad-hoc teaching, something which can be challenging in a busy ED.  Although many of the patients spoke fluent English, this was less common in the older patients, where the medical student’s skills as a translator became invaluable. Medical students appeared to enjoy these shifts, particularly where they were paired with a senior doctor keen on teaching. I think this is something we could certainly consider adopting at home. During their ED placements, students are also scheduled to do regular shifts where they see patients more autonomously and discuss cases with seniors.

The mix of presenting complaints was familiar: chest pain, breathlessness, collapses, head injuries, palpitations, mental health problems and complex frail patients with falls and confusion. And of course, after a particularly sunny Saturday evening, the inevitable alcohol and drug-related attendances were well represented! Ambulance crews would pre-alert the nurse in charge where necessary via phone and would send ECGs suspicious for STEMI ahead electronically for review on a big screen by a senior ED doctor, so that a decision on diverting to PCI could be made.

As in Scotland, Iceland’s EDs face increasing issues of overcrowding and exit block, particularly in relation to insufficient bed capacity and social care availability. There is currently no time standard in place in the ED in Iceland, with the average time from decision-to-admit to a patient leaving the ED sitting around 16 hours. As a result, the CDU here is generally full of “admitted” patients awaiting inpatient beds and it is not uncommon for patients to be on trolleys in the ED corridors for many hours and sometimes days. This is compounded by the familiar issue of increasing complex presentations in the frail elderly population, many of whom I saw during my shifts. These challenges appear to have caused a significant strain on the department in recent years, with resultant concerns for EM training, job satisfaction and job sustainability. Part of the solution may be on the horizon, with a bigger hospital in the pipeline.

There were plenty of nursing and clinical support around, all working efficiently and pro-actively. When seeing majors patients, I found they were almost always already on a trolley, changed into a gown with observations completed, usually in addition to bloods and an ECG. This allowed me to see patients quickly and focus on patient assessment, decision making and teaching. Patients were moved in and out of cubicles fairly promptly, helping to best utilise the limited cubicle space.

The IT system in use was impressive, with some very useful features, having been custom-developed and continually adapted with the input of the ED staff,. The user interface gives a familiar list view of the whole department on one screen, with most information such as observations, SBARs, jobs, results, referrals and pictures of the named nurse and doctor immediately viewable for each patient, rather than requiring separate page navigation. Patient discharge prescriptions were made electronically available immediately at any pharmacy, so patients could pick up their discharge medications without requiring a paper script. There was also the ability to easily instant message any staff member to ask them to do a job such as a repeat set of observations or adding a lab blood test, rather than requiring a phone call or finding the staff member. This was helped by plentiful computer availability for all clinical staff. It was impressive to see that the department was truly paperless, with all documentation, prescribing, and ordering and reviewing of tests done on the same computer interface. It was a great example of how a small scale custom-made IT solution can significantly benefit the running of an ED.

At the end of my first week I spent a day out on the ambulance with one of the city’s paramedic teams, and toured the shared emergency services headquarters. I will be doing more of this over the next couple of weeks, so will report back on this then. Overall it has been a very enjoyable and insightful first week in Iceland and I am very much looking forward to the rest of my time here!

'What matters to you?' #WMTY20

“It matters to me that I have a way for my voice to be heard even when I find it difficult to communicate due to being unwell, tired, in pain or distressed.”

No patient visiting the Emergency Department is having a ‘good day’. We see people when they are at their lowest. We place them in an unfamiliar, bustling environment and we expect them to be able to advocate for themselves. For many people this is an impossible task. So how can we help ensure our patients voice is heard?

The Emergency Department at the Royal Infirmary of Edinburgh, independent mental health advocacy organisation AdvoCard and people with lived experience of mental health issues, have been working in collaboration to improve the experience of ED patients and decrease their anxiety over an ED attendance. We have used data from AdvoCards ‘All & Equal’ project (http://www.advocard.org.uk/wp-content/uploads/2016/08/AE-All-Equal-FINAL.pdf ) and from our subsequent collaborative work to look at how we can bring ‘What matters to you?’ in to our ED environment at a time when the combination of illness and anxiety may mean our patients struggle to articulate the answer.

Together we have worked to produce a wallet sized Emergency Card on which patients can record their emergency contacts/ advocates and their wishes and concerns under the headings ‘I want you to know that…’ and ‘It matters to me that….’. The cards were launched over summer 2019 and we have been delighted with the uptake. We hope the cards will decrease the anxiety felt by patients at the thought of attending the ED and promote better communication between our patients and all those involved in their care should they have to visit.

If you are interested in using the cards either personally or in your organisation please feel free to download this jpeg for printing.  (See below for tips for printing.)

 If you live in Edinburgh and have mental health issues or work in the mental health sector in Edinburgh and would like a copy or copies of the printed cards please contact Becky at AdvoCard - becky@advocard.org.uk or 0131 554 5307.

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If you live in Edinburgh and have lived experience of mental health issues AdvoCard are keen to hear your views on the pandemic and lockdown.

What services do you need? What is working well? What could be better? Read more here:

http://www.advocard.org.uk/2020/05/what-do-you-need/ Questionnaire open until 2nd August.

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Tips for printing the card

Put JPEGs (A4 size) into a single document

Make sure that your printers settings are set to:

 -       Landscape orientation

-       Print on both sides

-       Flip on short edge

 There are three cards per page.  You can use the outer edges of the boxes as a guide to cut around.