Anaesthesia and critical care in unusual and transport environments: Overview

Since 1999 the Canadian Journal of Emergency Medicine is the publication platform for the communication and exchange of current work and ideas inspiring excellence in emergency medical care; it is an essential resource for emergency physicians in rural, urban or academic settings that reflect the growing interest in emergency medicine, both as a medical discipline and an expanding field for research. It is one of the top journals in its field and is the respected official journal of the Canadian Association of Emergency Physicians.

Abstract
Intrahospital transport of anesthetized and critically ill children is a routine event that carries myriad risks. Patients with a vast array of conditions are transported between the intensive care unit, procedural and diagnostic imaging suites, emergency department, and other areas. Given this complexity, the range of potential adverse events is large. Improving safety during transport will require a broad and holistic approach. This review will inform pediatric anesthesiologists on the best approach to improve their care and patient safety during transport by identifying common error traps, with both individual- and system-level countermeasures. The error traps include the failure to fully weigh all risks, costs, and benefits associated with transport for a procedure or test; secure appropriate resources for transport and at every destination; provide pertinent information during transfers of care; anticipate physical and physiological changes associated with transport; and execute the plan effectively as a team. Countermeasures include multidisciplinary discussion and resource optimization; use of systematic tools, standardized communication, and checklists to improve processes of care; encouraging the prioritization of a culture of safety around transport; and adapting the team composition and leadership style to suit the specific clinical scenario.

Abstract
Introduction: Non-traumatic back pain commonly leads people to seek health care from paramedics via triple-zero (emergency phone number in Australia), yet the management approaches by providers of ambulance services remain unclear.

Study objectives: This study aims to investigate paramedic management of non-traumatic back pain in New South Wales (NSW), Australia, including the call characteristics, provisional diagnoses, and the clinical care being delivered by paramedics.

Methods: This study is a retrospective analysis of NSW Ambulance computer-aided dispatch and electronic medical records from January 1, 2017 through December 31, 2022. Adults who sought ambulance service with a chief complaint of back pain, were triaged as non-traumatic back pain, and subsequently received treatment by paramedics were included. Multivariable logistic regression models were used to explore factors associated with primary outcomes; ambulance transport, opioid use, and use of medication combinations were reported as odds ratios (ORs).

Results: There were 73,128 calls to NSW Ambulance with a chief complaint of back pain that were triaged as non-traumatic back pain. Of these, 54,444 (74.4%) were diagnosed with spinal pain, of which 52,825 (97.1%) were categorized by the paramedic as back or neck pain, 1,573 (2.9%) as lumbar radicular pain, and 46 (0.1%) as serious spinal pathology. Eight out of ten patients with spinal pain were transported to emergency departments. The medicine most administered by a paramedic was an opioid (37.4% of patients with spinal pain). Older patients (OR = 1.36; 95% CI, 1.30 to 1.44) were more likely to be transported to an emergency department. Patients with moderate (OR = 4.39; 95% CI, 4.00 to 4.84) and severe pain (OR = 18.90; 95% CI, 17.18 to 20.79) were more likely to be administered an opioid.

Conclusions: Paramedic management of non-traumatic back pain in NSW typically results in the administration of an opioid and transport to an emergency department.