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BACKGROUND: The optimal response to a major incident in a road tunnel involves efficient decision-making among the responding emergency services (fire and rescue services, police, and ambulances). The infrequent occurrence of road tunnel incidents may entail unfamiliarity with the tunnel environment and lead to uncertain and inefficient decision-making among emergency services commanders. Ambulance commanders have requested tunnel-specific learning materials to improve their preparedness.

OBJECTIVE: We aimed to assess decision-making among ambulance commanders in simulated road tunnel incidents after they had participated in a tunnel-specific e-learning course designed to support timely and correct decisions in this context.

METHODS: We conducted a web-based intervention study involving 20 participants from emergency medical services in Sweden who were randomly allocated to a test or control group. The control group (n=10, 50%) received a lecture on general incident management, while the intervention group (n=10, 50%) completed an e-learning course consisting of 5 modules focused on tunnel structure, safety, and collaboration in response. The participants took part in 2 simulation-based assessments for ambulance commander decision-making in major road tunnel incidents 1 month and 6 months after their allocated study intervention. In each simulation, the participants decided on the best course of action at 15 independent decision points, designed as multiple-choice questions. The primary outcome was the correct response to the question regarding how to appropriately enter the road tunnel. The secondary outcome measurements were correct or incorrect responses and the time taken to decide for each of the 15 decisions. Limited in-depth follow-up interviews were conducted with participants (n=5, 25%), and collected data were analyzed using qualitative content analysis.

RESULTS: All 20 participants completed the first simulation, and 16 (80%) completed the second. The main finding was that none (0/20, 0%) of the participants correctly answered the question on entering the tunnel system in the 1-month assessment. There were no significant differences between the groups (P=.59; 2-sample test of proportions) in the second assessment. The e-learning course was not associated with more correct answers at the first assessment, including accounting for participant factors (mean difference between groups: -0.58 points, 95% CI -1.88 to 0.73; P=.36). The e-learning course was also not associated with a shorter time to completion compared to the nonintervention group in either assessment. Interviews identified 3 categories linked to the main outcome: information (lack of), risk (limited knowledge and equipment), and mitigation (access to maps and aide-mémoire).

CONCLUSIONS: Participation in a tunnel-specific e-learning course did not result in a measurable change in ambulance commanders' decision-making behavior during simulated road tunnel incidents. The observed hesitation to enter the road tunnel system may have several plausible causes, such as the lack of actionable intelligence and tunnel-specific plans. This novel approach to assessing commander decision-making may be transferable to other educational settings.

Background: Increasing mountain activity and decreasing participant preparedness, as well as climate change, suggest needs to tailor mountain rescue. In Sweden, previous medical research of these services are lacking. The aim of the study is to describe Swedish mountain rescue missions as a basis for future studies, public education, resource allocation, and rescuer training.

Methods: Retrospective analysis of all mission reports in the national Swedish Police Registry on Mountain Rescue 2018–2022 (n = 1543). Outcome measures were frequencies and characteristics of missions, casualties, fatalities, traumatic injuries, medical conditions, and incident mechanisms.

Results: Jämtland county had the highest proportion of missions (38%), followed by Norrbotten county (36%). 2% of missions involved ≥ 4 casualties, and 44% involved ≥ 4 mountain rescuers. Helicopter use was recorded in 59% of missions. Non-Swedish citizens were rescued in 12% of missions. 37% of casualties were females. 14% of casualties were ≥ 66 or ≤ 12 years of age. Of a total 39 fatalities, cardiac event (n = 14) was the most frequent cause of death, followed by trauma (n = 10) and drowning (n = 8). There was one avalanche fatality. 8 fatalities were related to snowmobiling, and of the total 1543 missions, 309 (20%) were addressing snowmobiling incidents. Of non-fatal casualties, 431 involved a medical condition, of which 90 (21%) suffered hypothermia and 73 (17%) cardiovascular illness.

Conclusions: These baseline data suggest snowmobiling, cardiac events, drownings, multi-casualty incidents, and backcountry internal medicine merit future study and intervention.

På uppdrag av Socialstyrelsen har Kunskapscentrum Katastrofmedicin i Umeå genomfört en rapporti syfte att kartlägga användningen av alternativa sjuktransportfordon i Ukraina efter Rysslands fullskaliga invasion. Studien utgör en del av ett regeringsuppdrag för att stärka den nationella samordningen av sjuktransporter vid fredstida kriser, höjd beredskap och krig. Metoden omfattade en litteraturgenomgång samt kvalitativa intervjuer med sjukvårdspersonal, fordonsmekaniker och representanter för hjälporganisationer i Ukraina och Sverige. Resultaten visar att alternativa fordon använts för att hantera brist på resurser, anpassa sig till hotfulla miljöer och möjliggöra fortsatt evakuering nära frontlinjen. Kamouflering lyfts fram som en strategi för ökat skydd, men medför etiska och juridiska risker om skyddsemblem inte synliggörs tydligt. Författarna rekommenderar att Sverige utvecklar riktlinjer för anpassning av sjuktransportfordon i krigssituationer, inklusive utbildning i säkerhet, beslutsfattande och internationell humanitär rätt.

Objective: Vehicle materials developments raise concerns about new patterns of vehicle fire toxic gas emissions. This study aimed to describe toxicologic components in a recent material of fatal car crashes on Swedish roads in which the vehicle caught fire and compare the results to a previous material.

Methods: Retrospective registry study. All fatal car crashes with fire in Sweden 2009–2018 were extracted from the Swedish Transport Administration’s In-Depth Studies Database and compared with an earlier study of the time period 1998–2008.

Results: A total of 79 crashes and 94 fatalities were included. Carbon monoxide (COHb) blood levels >10% were found in 13 cases. Hydrogen cyanide (HCN) blood levels 0.1–1.7 µg/g were found in 10 cases. In 31 of the cases the person had a blood alcohol level (BAC) >0.2‰, which is the legal driving limit in Sweden. A total of 15 people died due to burn injuries and 2 individuals died due to toxic gas emissions without any other fatal traumatic injury. Total number of deaths in fire-related crashes halved from 181 (1998–2008) to 94 (2009–2018) but the percentage of fatalities in burning vehicles was unaltered (5% vs. 6%). The proportion of fatalities with HCN in the blood increased from 2% between 1998–2008 to 10% during 2009–2018 (p = 0.006). The age of the car involved in a crash increased by 0.26 years per calendar year (p = 0.001).

Conclusions: The proportion of fatalities with measured levels of HCN in the blood has increased. Eleven of the 15 burn injury fatalities had high levels of alcohol, HCN, or COHb, possibly contributing to an inability to leave a burning vehicle. Faster rescue brought by improved specific education and training of ambulance and rescue services personnel may be of future importance, as may on-scene antidote administration and revised regulations of vehicle flammability.

Purpose: Major incidents in road tunnels remain a collaborative challenge for the emergency services (fire and rescue service, police and ambulance), emergency dispatch centres (EDCs) and infrastructure owners. The aim of this paper is to investigate how collaborative partners to the ambulance services perceive the rescue effort and to identify factors that may influence its efficiency.

Design/methodology/approach: Focus group and individual interviews were conducted with 19 participants who were infrastructure owners or had operational or tactical responsibilities with the emergency services or EDCs in two regions in Sweden with multiple road tunnels. The collected data were analysed using qualitative content analysis.

Findings: Three main categories described efficiency factors during and after an incident: (1) coordinating the initial information (using a shared terminology), (2) achieving situational awareness (identifying those persons in need) and (3) lessons (not) learnt (lack of joint tactical plans and exercises). The emerging theme was access, assess and evaluate.

Practical implications: The findings suggest that establishing national policies and collaborative forums might yield more efficiently managed rescue efforts in road tunnel incidents in Sweden and other countries with similar organisational structures.

Originality/value: This study offers new insights on interoperability during responses to complex underground incidents.

Background: In chemical incidents, infrequent but potentially disastrous, the World Health Organization calls for inter-organizational coordination of actors involved. Multi-organizational studies of chemical response capacities are scarce. We aimed to describe chemical incident experiences and perceptions of Swedish fire and rescue services, emergency medical services, police services, and emergency dispatch services personnel.

Methods: Eight emergency service organizations in two distinct and dissimilar regions in Sweden participated in one organization-specific focus group interview each. The total number of respondents was 25 (7 females and 18 males). A qualitative inductive content analysis was performed.

Results: Three types of information processing were derived as emerging during acute-phase chemical incident mobilization: Unspecified (a caller communicating with an emergency medical dispatcher), specified (each emergency service obtaining organization-specific expert information), and aligned (continually updated information from the scene condensed and disseminated back to all parties at the scene). Improvable shortcomings were identified, e.g. randomness (unspecified information processing), inter-organizational reticence (specified information processing), and downprioritizing central information transmission while saving lives (aligned information processing).

Conclusions: The flow of information may be improved by automation, public education, revised dispatcher education, and use of technical resources in the field. Future studies should independently assess these mechanism’s degree of impact on mobilisation of emergency services in chemical incidents.

Background. Fixed object parachuting, commonly known as BASE (Building, Antenna, Span, Earth) Jumping, was revolutionized by the introduction of wingsuits in the 1990s. Wingsuit BASE Jumping (WSBJ) has since surged both in overall popularity, and more recently, in its contribution to the rising rate of BASE fatalities. Risks associated with WSBJ and its position within the broader BASE community have been explored in previous work. However, the practical considerations of a nominal wingsuit flight, the aero-dynamic underpinnings of WSBJ, and discussions regarding the pilot’s decision-making processes and in-flight goals are nearly absent from the current literature.

Methods. This expert opinion article was developed through years of experience in the BASE environment and analysis of in-flight altimetry and glide data from both the authors and through contributors in the wingsuit BASE community. Previous authors’ rigorous investigations and thorough work on safe, high-performance WSBJ are also discussed.

Results. This concept article takes a very practical approach to WSBJ, walking through the optimal procedure for a safe jump from exit to parachute deployment.

Conclusions. Strong conceptual foundation, focus on technique, lessons from relevant accidents, and emergency planning all contribute to a successful wingsuit BASE jump.

The objective was to illuminate the experience of injuries and the process of injury reporting within the Swedish skydiving culture. Data contained narrative interviews that were subsequently analyzed with content analysis. Seventeen respondents (22–44 years) were recruited at three skydiving drop zones in Sweden. In the results injury events related to the full phase of a skydive were described. Risk of injury is individually viewed as an integrated element of the recreational activity counterbalanced by its recreational value. The human factor of inadequate judgment such as miscalculation and distraction dominates the descriptions as causes of injuries. Organization and leadership act as facilitators or constrainers for reporting incidents and injuries. On the basis of this study it is interpreted that safety work and incident reporting in Swedish skydiving may be influenced more by local drop zone culture than the national association regulations. Formal and informal hierarchical structures among skydivers seem to decide how skydiving is practiced, rules are enforced, and injuries are reported. We suggest that initial training and continuing education need to be changed from the current top-down to a bottom-up perspective, where the individual skydiver learns to see the positive implications of safety work and injury reporting.

Background: Physical inactivity is considered to be the strongest individual risk factor for poor health in Sweden. It has been shown that increased physical activity can reduce hypertension and the risk of developing cardiovascular diseases. The objective of the present pilot study was to investigate whether a combination of Motivational Interviewing (MI) and Physical Activity on Prescription (PAP) would increase leisure exercise time and subsequently improve health-related variables.

Methods: This pilot study was of a repeated measures design, with a 15 months intervention in 31 patients with mild to moderate hypertension. Primary outcome parameter was leisure exercise time and secondary outcome parameters were changes in blood pressure, Body Mass Index (BMI), waist circumference, lipid status, glycosylated haemoglobin (HbA1c) and maximal oxygen uptake (VO_{2 max}). Assessments of the outcome parameters were made at baseline and after 3, 9 and 15 months.

Results: Leisure exercise time improved significantly from < 60 min/week at baseline to a mean activity level of 300 ( 165) minutes/week at 15 months follow up. Furthermore, statistically significant improvements (p < 0.05) were observed in systolic (-14,5 8.3 mmHg) and diastolic blood pressure (-5,1 5.8 mmHg), heart rate (-4.9 8.7 beats/min, weight (-1.2 3.4 kg) BMI -0.6 1.2 kg/m2), waist circumference (-3.5 4.1 cm) as well as in VO_{2 max}(2.94 3.8 ml/kg and 0.23, 0.34 lit/min) upon intervention as compared to baseline.

Conclusions: A 15 month intervention period with MI, in combination with PAP, significantly increased leisure exercise time and improved health-related variables in hypertensive patients. This outcome warrants further research to investigate the efficacy of MI and PAP in the treatment of mild to moderate hypertension.