The Swedish-Norwegian co-operation
The first phase of a rescue operation like this is almost always chaotic and information tends to be deficient. The initial distress call was vague, and circumstances and the number of missing persons were unknown. The accident took place in an area far from professional rescue personnel. Although local rescuers did a formidable job on scene, one can in retrospect point out that more advanced resources should have been routed towards the scene of accident in an earlier phase. A request for Norwegian assistance was made about 1 h 20 m after the accident. With the wind conditions that day three helicopters from Norway (one SAR helicopter and two ambulance helicopters), each manned with an anesthesiologist and capacity to carry rescue divers, could have been on scene within 1 h. With sufficient resources patient 2 could have been transported to a hospital with ECMO competence in case his condition deteriorated. Earlier request for Norwegian assistance could have brought patient 1 and 3 to hospital earlier.
On scene, the Östersund HEMS-crew was confronted with an overwhelming scenario with multiple hypothermia victims, but realistically without capacity to handle more than one patient. Prior to this accident there existed no protocols, neither for pre-hospital workers nor for emergency call dispatch centers, allowing hypothermia victims requiring extracorporeal rewarming (ECR) to be admitted to a nearer ECMO facility across the national border. However, medical co-operation between Sweden and Norway has historically been good in our region, and ambulance helicopters sometimes even operate on the “wrong” side of the border. Faced with a lifeless young patient with profound hypothermia (grade IV of IV according to the Swiss hypothermia classification) [
1] and an additional 60 min flight time to the nearest ECR-center in Sweden, the HEMS-crew decided wisely to transport Patient 1 to Trondheim. Necessary clearances were handled quickly between the Swedish and Norwegian emergency call centers. Direct radio communication between helicopter and hospital/ECR-team was technically impossible at the time. Even though Scandinavian languages are quite similar, a language barrier led the ECR-team to think they were about to receive a couple of two-year-olds (the Swedish word for “teenager” had been confused with the Norwegian word for “two-year-old”). This misunderstanding was sorted out mere minutes before the arrival of Patient 1.
According to the Swiss hypothermia classification, Patient 2 had clinically stage II/III hypothermia (unconscious/impaired consciousness) when he was picked up from the water, indicating moderate to severe hypothermia. The pre-hospital course has not been available in full detail, but at least his sensorium was affected and he had intermittent atrial fibrillation indicating a possible circulatory impact of the hypothermia. Guidelines for management of accidental hypothermia advice that patients with moderate and severe hypothermia (Swiss hypothermia classification, stage II and III) with concomitant unstable circulation (systolic blood pressure < 90 mmHg, ventricular arrhythmias or core temperature < 28 °C) should be transported directly to an ECMO/CPB center. Whether or not Patient 2 should have been brought to a hospital with ECR capability is debatable. Ideally, we think he probably should have, based on initial clinical signs, time of exposure in the cold waters, likelihood of temperature afterdrop, and last but not least the distance to the nearest ECR-center with capacity (Umeå, Sweden) had his condition deteriorated. Core temperature is often difficult to obtain in a pre-hospital setting. This said, we acknowledge that there were insufficient resources on scene, and we agree with the priorities made to move him by ambulance to the nearest hospital.
Patient 3 also had Swiss grade IV, severe and profound hypothermia. The decision to bring him to Trondheim University Hospital was probably psychologically easier for the pre-hospital crew, Trondheim being home base for the ambulance helicopter, but it underlines the importance of adequate communication between pre-hospital and in-hospital services. ECR is a treatment demanding large resources, both personnel and equipment, and is in Scandinavia available only in cardiothoracic surgical centers. In Norway, the cardiothoracic units are small, and the capacity for receiving patients in need of ECR is variable, even within the same institution, and depends on available personnel, number of available ECMO/CPB machines, and ICU capacity. A higher number of victims in need of ECR in this case would probably have exceeded our capacity, and would have demanded patients being routed to other destinations.
Studying this rescue operation one does find room for improvement, especially when it comes to communication, but it has also shown that good co-operation across national borders can produce excellent treatment results. In the aftermath of this accident routines have been reviewed by a Swedish-Norwegian regional meeting, and protocols were created to make similar incidences in the future run more smoothly. Communication being the key word, it mostly boils down to optimizing lines of communication and finding strategies to improve communication from pre-hospital to in-hospital staff and vice versa. Ongoing implementation of digital radio communications in both countries and harmonizing radio frequencies will hopefully also be a powerful tool to this end.
The ECMO center at Karolinska University Hospital was contacted on the morning after the accident. Being the largest ECMO center in Scandinavia, we turned to them for discussion on when transfer of the patients would be practicle. Given their clinical state, and since the patients required all of our ECMO capacity, we agreed that the patients be retrieved on ECMO the same day. In retrospect we find this was the best solution for all parties: The patients were treated further in a highly experienced and specialized hospital. The patients were brought closer to home and their next of kin. The ECMO capacity of our hospital was restored in case of new emergencies.