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Niccolas Bertote Guarda F, Nucci Galetti I, Regina Dos Santos C, Marchioni C. Self-medication cases reported to a poison information center in Brazil from 2014 to 2020. Clin Toxicol (Phila) 2024; 62:190-196. [PMID: 38501499 DOI: 10.1080/15563650.2024.2326845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/29/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Self-medication is the use of drugs to treat self-diagnosed illnesses or symptoms, on one's own initiative, without the guidance of a healthcare professional. Poison centers play an important role in understanding the relationship between self-medication and poisoning. The objective of this study is to evaluate the clinical and epidemiological profile of patients exposed to and/or poisoned by different drugs through self-medication. METHODS This retrospective, cross-sectional, and descriptive study analyzed data from 2014 to 2020, provided by the Toxicological Information and Assistance Center of Santa Catarina, Brazil. Data were selected, tabulated, and analyzed by using descriptive statistics and group comparison with the chi-square test or Fisher's exact test. A P value <0.05 was considered statistically significant. RESULTS There were 683 cases of self-medication identified. Most patients were female (62.8 percent) and between 20 and 29 years old (26.1 percent). A toxic dose of a substance was administered in only 22.8 percent of the cases, and five deaths were recorded. The most commonly used medications were anxiolytics (18 percent), followed by analgesics and antipyretics (15.4 percent). Paracetamol was the drug used in three of the five cases that resulted in deaths. DISCUSSION This study demonstrates the prevalence of self-medication among women aged between 20 and 29 years old. Statistical analysis failed to show a relationship between a toxic dose and clinical manifestations. Anxiolytics, analgesics, and antipyretics are the most reported medications probably because healthcare professionals are mostly the ones who contact the center. Analgesics and antipyretics account for more than fifty percent of the deaths caused by self-medication in the present report. Some limitations such as secondary sources are related. CONCLUSION We highlight the importance of health professionals in promoting the rational use of medicines, as well as poison centers in assisting the population and raising their awareness regarding the issue.
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Affiliation(s)
| | - Isabela Nucci Galetti
- Pharmacy, Federal University of Santa Catarina, St. Delfino Conti S/N, Florianopolis, Santa Catarina, Brazil
| | - Claudia Regina Dos Santos
- Department of Pathology, Federal University of Santa Catarina, St. Delfino Conti S/N, Florianopolis, Santa Catarina, Brazil
| | - Camila Marchioni
- Department of Pathology, Federal University of Santa Catarina, St. Delfino Conti S/N, Florianopolis, Santa Catarina, Brazil
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Dax F, Waibel M, Kneißl K, Prückner S, Lazarovici M, Hoffmann F, Hegenberg K. Analyzing emergency call volume, call durations, and unanswered calls during the first two waves of the COVID-19 pandemic compared to 2019: An observational study of routine data from seven bavarian dispatch centres. Heliyon 2024; 10:e24839. [PMID: 38333836 PMCID: PMC10850415 DOI: 10.1016/j.heliyon.2024.e24839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 02/10/2024] Open
Abstract
Background The spread of the COVID-19 pandemic and the corresponding implementation of measures such as stay-at-home orders and curfews had a major impact on health systems, including emergency medical services. This study examined the effect of the pandemic on call volumes, duration of calls and unanswered calls to the emergency number 112. Method For this retrospective, descriptive study, 986,650 calls to seven emergency dispatch centres in Bavaria between January 01, 2019 and May 31, 2021 were analysed. The absolute number of calls and calls per 100,000 inhabitants as well as the number of unanswered calls are reported. The Mann‒Whitney U test was used to compare mean call durations between 2019 and 2020/2021 during several periods. Results Call volume declined during the pandemic, especially during periods with strict lockdown restrictions. The largest decline (-12.9 %) occurred during the first lockdown. The largest reduction in the number of emergency calls overall (-25.3 %) occurred on weekends during the second lockdown. Emergency call duration increased, with the largest increase (+13 s) occurring during the "light" lockdown. The number of unanswered calls remained at a similar level as before the pandemic. Conclusion This study showed that the studied Bavarian dispatch centres experienced lower call volumes and longer call durations during the first two waves of the COVID-19 pandemic (up to May 2021). Longer call durations could be the result of additional questions to identify potentially infectious patients. The fact that the number of unanswered calls hardly changed may indicate that the dispatch centres were not overwhelmed during the study period.
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Affiliation(s)
- Florian Dax
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
| | - Moritz Waibel
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
| | - Katharina Kneißl
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
| | - Stephan Prückner
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
| | - Marc Lazarovici
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
| | - Florian Hoffmann
- Dr. von Haunersches Kinderspital, Kinderklinik und Kinderpoliklinik, Klinikum der Universität München, LMU München, Lindwurmstr. 4, 80337, München, Germany
| | - Kathrin Hegenberg
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336, München, Germany
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Hegenberg K, Althammer A, Gehring C, Prueckner S, Trentzsch H. Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany. Healthcare (Basel) 2023; 11:1983. [PMID: 37510425 PMCID: PMC10379196 DOI: 10.3390/healthcare11141983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND AND IMPORTANCE The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls. OBJECTIVE To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods. DESIGN, SETTING AND PARTICIPANTS This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany. OUTCOMES MEASURE AND ANALYSIS We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates. MAIN RESULTS Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave. CONCLUSIONS Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.
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Affiliation(s)
- Kathrin Hegenberg
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Alexander Althammer
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Christian Gehring
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Stephan Prueckner
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
| | - Heiko Trentzsch
- Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwigs-Maximilians-Universität München, Schillerstr. 53, 80336 Munich, Germany
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Nishimura T, Suga M, Ishihara S, Nakayama S, Nakao A, Naito H. Influence of coronavirus disease 2019 case surges on prehospital emergency medical service for patients with trauma in Kobe, Japan. Acute Med Surg 2023; 10:e829. [PMID: 36968647 PMCID: PMC10034623 DOI: 10.1002/ams2.829] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/08/2023] [Indexed: 03/25/2023] Open
Abstract
Aim In the current era of the coronavirus disease 2019 (COVID‐19) pandemic, the responsiveness of emergency medical service (EMS) transport for patients with internal illness is often delayed. However, the influence of the COVID‐19 pandemic on prehospital transport for patients with trauma has not yet been fully elucidated. This study aims to examine the effect of COVID‐19 case surges on EMS transport for patients with trauma during the COVID‐19 states of emergency in Kobe, Japan. Methods EMS data during the states of emergency were compared with those in the 2019 prepandemic period. The incidence of difficulty securing hospital acceptance (four or more calls to medical institutions and ambulance staying at the scene for 30 min or more) was evaluated as a primary outcome. Secondary outcomes were the time spent at the trauma scene and the number of calls requesting hospital acceptance. The time spent at the trauma scene was stratified by trauma severity. Results The incidence of difficulty securing hospital acceptance increased (1.2% versus 3.2%, P < 0.01). Logistic regression analysis revealed that the duration of the states of emergency was associated with difficulty securing hospital acceptance (odds ratio [OR] 2.08, 95% confidence interval 1.77–2.45; P < 0.01). Although the mean time spent at the trauma scene among the less severe, moderately severe, and severe trauma groups was prolonged, the time for the life‐threatening group did not change. The number of request calls increased during the states of emergency. Conclusion Difficulty securing hospital acceptance increased; however, the time spent at the trauma scene did not significantly change for the life‐threatening group.
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Affiliation(s)
- Takeshi Nishimura
- Department of Emergency and Critical Care MedicineOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical SciencesOkayamaJapan
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKobeJapan
| | - Masafumi Suga
- Department of Emergency and Critical Care MedicineOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical SciencesOkayamaJapan
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKobeJapan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKobeJapan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care MedicineHyogo Emergency Medical CenterKobeJapan
| | - Atsunori Nakao
- Department of Emergency and Critical Care MedicineOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical SciencesOkayamaJapan
| | - Hiromichi Naito
- Department of Emergency and Critical Care MedicineOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical SciencesOkayamaJapan
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Vuilleumier S, Spichiger T, Dénéréaz S, Fiorentino A. Not only COVID-19 disease impacts ambulance emergency demands but also lockdowns and quarantines. BMC Emerg Med 2023; 23:4. [PMID: 36635638 PMCID: PMC9836922 DOI: 10.1186/s12873-023-00772-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The pandemic has impacted both patients infected by the SARS-CoV-2 virus and patients who seek emergency assistance due to other health issues. Changes in emergency demands are expected to have occurred during the pandemic, the objective of this investigation is to characterize the changes in ambulance emergency demands during the first year of the COVID-19 pandemic in the Vaud State of Switzerland. The goal of this research is to identify the collateral effects of the COVID-19 pandemic on emergency demands. To do so, this study quantifies the differences in health issues, level of severity, and patients' sociodemographic characteristics (age, location, gender) prior to and during the outbreak. METHOD This is a retrospective, descriptive and comparative statistical analysis of all ambulance emergency missions from 2018 to 2020 (n = 107,150) in the State of Vaud in Switzerland. Variables analyzed were the number of ambulance missions, patient age and gender, health issues, severity (NACA scores), number of non-transports, mission times and locations. Variables were compared between prepandemic and pandemic situations across years and months. Comparative analysis used bivariate analysis, χ2 test, Student's t test, and Mann‒Whitney U test. RESULTS The pandemic has had two major impacts on the population's emergency demands. The first appears to be due to COVID-19, with an increase in respiratory distress cases that doubled in November 2020. The second relates to the implementation of lockdown and quarantine measures for the population and the closures of restaurants and bars. These might explain the decrease in both the number of traumas and intoxications, reaching more than 25% and 28%, respectively. An increase in prehospital emergency demands by the older population, which accounted for 53% of all demands in 2020, is measured. CONCLUSION Collateral effects occurred during 2020 and were not only due to the pandemic but also due to protective measures deployed relative to the population. This work suggests that more targeted reflections and interventions concerning the most vulnerable group, the population of people 65 and older, should be of high priority. Gaining generalizable knowledge from the COVID-19 pandemic in prehospital settings is critical for the management of future pandemics or other unexpected disasters.
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Affiliation(s)
- Séverine Vuilleumier
- La Source School of Nursing, University of Applied Sciences and Art Western Switzerland (HES-SO), Lausanne, CH-1004 Switzerland
| | - Thierry Spichiger
- grid.507562.3ES ASUR, Vocational Training College for Registered Paramedics and Emergency Care, Le Mont- sur-Lausanne, CH-1052 Switzerland
| | - Sandrine Dénéréaz
- grid.507562.3ES ASUR, Vocational Training College for Registered Paramedics and Emergency Care, Le Mont- sur-Lausanne, CH-1052 Switzerland
| | - Assunta Fiorentino
- La Source School of Nursing, University of Applied Sciences and Art Western Switzerland (HES-SO), Lausanne, CH-1004 Switzerland
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Pitt IL. The system-wide effects of dispatch, response and operational performance on emergency medical services during Covid-19. HUMANITIES & SOCIAL SCIENCES COMMUNICATIONS 2022; 9:412. [PMID: 36415345 PMCID: PMC9672593 DOI: 10.1057/s41599-022-01405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
In this paper, we analyze the Fire Department of New York City's pre-hospital emergency medical services dispatch data for the period of March 20, 2019-June 13, 2019, and the corresponding Covid lockdown period of March 20, 2020-June 13, 2020. A fixed effects negative binomial model is used to estimate the heterogeneity effects of average ambulance travel or response times on the daily volume of emergency calls, year, day of the week, dispatcher-assigned medical emergency call type, priority rank, ambulance crew response, borough and an offset for missing calls. We also address the limitations of other non-parametric Covid studies or parametric studies that did not properly account for over-dispersion. When our model is estimated and corrected for clustered standard errors, fixed effects, and over-dispersion, we found that Wednesday was the only day of the week that was most likely to increase travel response time with an odd ratio of 6.91%. All grouped call types that were categorized showed significant declines in average travel time, except for call types designated as allergy and an odds ratio of 21.81%. When compared to Manhattan, Staten Island ambulance response times increased with an odds ratio of 19.05% while the Bronx showed a significant decline with an odds ratio of 31.92% advanced life support (ALS) and BLS ambulances showed the biggest declines in travel time with the exception of BLS assigned ambulance types and emergency priority rank of 6. Surprisingly, in terms of capacity utilization, the dispatch system was not as overwhelmed as previously predicted as emergency call volume declined by 8.83% year over year.
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Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe. Eur J Trauma Emerg Surg 2022; 48:4385-4402. [PMID: 35523966 PMCID: PMC9075714 DOI: 10.1007/s00068-022-01978-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/16/2022] [Indexed: 12/13/2022]
Abstract
Purpose This study investigated the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed. Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. All the comparative studies reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Only comparative clinical studies which investigated the year 2020 versus 2019 were eligible. Results 57 clinical investigations were included in the present study. Eight studies reported a reduction of the orthopaedic consultations, which decreased between 20.9 and 90.1%. Seven studies reported the number of emergency and trauma consultations, which were decreased between 37.7 and 74.2%. Fifteen studies reported information with regard to the reasons for orthopaedic and trauma admissions. The number of polytraumas decreased between 5.6 and 77.1%, fractures between 3.9 and 63.1%. Traffic accidents admissions dropped by up to 88.9%, and sports-related injuries dropped in a range of 59.3% to 100%. The overall reduction of the surgical interventions ranged from 5.4 to 88.8%. Conclusion The overall trend of consultations, surgeries, and rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the pre-pandemic era. Given the heterogeneities in the clinical evidence, results from the present study should be considered carefully. Level of evidence Level IV, systematic review.
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Ventura CAI, Denton EE, David JA, Schoenfelder BJ, Mela L, Lumia RP, Rudi RB, Haldar B. Emergency Medical Services Prehospital Response to the COVID-19 Pandemic in the US: A Brief Literature Review. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:249-272. [PMID: 35669176 PMCID: PMC9165654 DOI: 10.2147/oaem.s366006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022] Open
Abstract
This study aimed to analyze prehospital Emergency Medical Services (EMS) response to the COVID-19 pandemic in the US through a brief systematic review of available literature in context with international prehospital counterparts. An exploration of the NCBI repository was performed using a search string of relevant keywords which returned n=5128 results; articles that met the inclusion criteria (n=77) were reviewed and analyzed in accordance with PRISMA and PROSPERO recommendations. Methodical quality was assessed using critical appraisal tools, and the Egger’s test was used for risk of bias reduction upon linear regression analysis of a funnel plot. Sources of heterogeneity as defined by P < 0.10 or I^2 > 50% were interrogated. Findings were considered within ten domains: structural/systemic; clinical outcomes; clinical assessment; treatment; special populations; dispatch/activation; education; mental health; perspectives/experiences; and transport. Findings suggest, EMS clinicians have likely made significant and unmeasured contributions to care during the pandemic via nontraditional roles, ie, COVID-19 testing and vaccine deployment. EMS plays a critical role in counteracting the COVID-19 pandemic in addition to the worsening opioid epidemic, both of which disproportionately impact patients of color. As such, being uniquely influential on clinical outcomes, these providers may benefit from standardized education on care and access disparities such as racial identity. Access to distance learning continuing education opportunities may increase rates of provider recertification. Additionally, there is a high prevalence of vaccine hesitancy among surveyed nationally registered EMS providers. Continued rigorous investigation on the impact of COVID-19 on EMS systems and personnel is warranted to ensure informed preparation for future pandemic and infectious disease responses.
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Affiliation(s)
- Christian Angelo I Ventura
- Department of Graduate Medical Sciences, Boston University School of Medicine Boston, Boston, MA, USA
- Department of Health, Behavior and Society (Incoming), Johns Hopkins Bloomberg School of Public Health Baltimore, Baltimore, MD, USA
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Correspondence: Christian Angelo I Ventura, Tel +1 (732) 372-2141, Email ;
| | - Edward E Denton
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Department of Emergency Medicine, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA
| | - Jessica Anastacia David
- Department of Biochemistry and Microbiology, Rutgers University New Brunswick, Brunswick, NJ, USA
| | | | - Lillian Mela
- Department of Nursing, Simmons University Boston, Boston, MA, USA
| | - Rebecca P Lumia
- Department of Biology, Northeastern University Boston, Boston, MA, USA
| | - Rachel B Rudi
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
| | - Barnita Haldar
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham School of Medicine Birmingham, Birmingham, AL, USA
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Azbel M, Heinänen M, Lääperi M, Kuisma M. Correction to: Effects of the COVID-19 pandemic on trauma-related emergency medical service calls: a retrospective cohort study. BMC Emerg Med 2021; 21:140. [PMID: 34794385 PMCID: PMC8601770 DOI: 10.1186/s12873-021-00511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Michael Azbel
- Prehospital Emergency Care Services, Lapland Central Hospital, P.O. Box, 8041, FI-96101, Rovaniemi, Finland. .,Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, Finland.
| | - Mikko Heinänen
- Trauma Unit and Helsinki Trauma Registry, Helsinki University Hospital, P.O. Box 266, FI-00029, Helsinki, Finland.,Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mitja Lääperi
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, Finland
| | - Markku Kuisma
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, Finland
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