1. Pediatric Anaesthesia in remote /rural areas The Norwegian Challenges and Solutions Øyvind Skraastad, MD, PhD Assistant Professor Head of Division of Medical Emergencies and Critical Care Oslo University Hospital

2. Welcome to Norway The home of wilderness and beauty South – north distance Oslo – Finnmark equal to Oslo – Rome. North Cape 71° north Easternmost point of Norway, Vardø 31° east

3. Midnight at the arctic circle Four seasons - but stormy weather all year through Norway – remote beauty and wilderness

4. Nordland 38 456 km 2 Switzerland 41 290 km 2 Troms 25 877 km 2 Makedonia 25 333 km 2 Finnmark 48 618 km 2 Slovakia 48 845 km 2 471 000 inhabitants. 4,2 inhabitants per km 2 Each of them has 3 ½ m coast line Svalbard 61000 km² Population : 2600

5. Svalbard - Coal mining and tourists in an arctic desert

6. UNN Tromsø – Regional University Hospital

7. Norwegian Health Care system - regions Health Reform in 2001 Hospitals in 19 19 Counties 4 4 Health regions since 2007 Østfold Akershus Oslo Hedmark Oppland 262 417 505 185 543 585 188 639 182 746 Buskerud Vestfold Telemark Aust-Agder Vest-Agder 245 942 223 357 166 871 104 166 163 753 Rogaland Hordaland Sogn og Fjordane 401 079 455 800 106 977 Møre og Romsdal Sør-Trøndelag Nord-Trøndelag 245 183 277 013 129 489Counties Inhabitants Nordland Troms Finnmark 236 553 153 475 73 163 5 000000 Helse Nord Helse Sør Øst Helse Vest Helse Midt-Norge

8. Pediatric anaesthesia in Norway Mainly centralized –Planned surgery - pregnancies at risk, (maternal and fetal risk) –Emergencies - initial local stabilisation, transportation –Time before arriving in a regional hospital is up to 5-8 hrs after trauma or other emergencies in remote areas; - 2-3 hrs incl time of stabilizing in local hospitals - 2-3 hrs transport.

9. Organisation of pediatric anesthesia and surgery - Local community hospitals Children >2 years Primary responders to all pediatric emergencies, including traumas and neonates – stabilisation Acute orthopedic cases, acute abdomen, planned ENT surgery Level of pediatric surgery and anesthesia procedures dependent on local perioperative competence - turnover of staff Refer all other pediatric cases

10. Organisation of pediatric anesthesia and surgery - County Hospitals (19) Children > 1 year Do more advanced surgery and anesthesia than local community hospitals Incl pediatric orthopedic trauma Anaesthesia for MRI/CT scan More advanced pediatric ENT service Refer children <1 yr to regional hospitals, incl neonates. Refer all advanced surgery and children with comorbidity, trauma after stabilisation

11. Organisation of pediatric anesthesia and surgery – Regional hospitals (4) Children above GA 44 wks Pediatric traumatology, pediatric surgical programmes. All hospitals have pediatric anaestetists 3 hospitals refer advanced surgery, incl most neonates and (intensive care) to national services at Rikshospitalet Pediatric cardiac surgery Major comorbidity Primary surgery for congenital malformations to 1(2) specialized hospital(s)

12. Neonatal surgery Neonatal surgery – GA 44 wks Malformations: –Cardiac malformations – 60-80 per year –Gastrointestinal - 30-60, incl diaphragmatic hernias –CNS - less than 10 Complications of Low GA/LBW –Necrotizing enterocolitis –PDA closures Expremature –Closure of inguinal hernias -10-20 % of all premature born babies

13. Rikshospitalet - National Hospital Part of Oslo University Hospital National pediatric surgical services

14. The hospital – 10 years old A1 A2 B1 B2 C E1 E2 D1 D2

15. The major children's hospital in Norway In Oslo Rikshospitalet HF Outside Oslo Spesialsykehuset for Epilepsi Spesialsykehuset for Rehablitering Rikshospitalet – specialized and centralized pediatric surgery and care Pediatric cardiac surgery Pediatric neurosurgery Pediatric general surgery Pediatric transplantation services Advanced neonatal and pediatric intensiv care

16. Dilemmas and solutions The number of pediatric cases in the periphery is too small for training and developing skills and experience – BEST (Better systematic team – training for children) The distance from periphery to centralized care is too long when taking care of medical emergencies incl trauma cases. Solution: –Communication, Support and Transportation Teleradiology Emergency medical conferences Highly competent and avaliable transportation system 24/7/365

17. Bolle, Lien, Mjaaseth, Gilbert. Tidsskr Nor Legeforen 2013; 133 Videobased emergency conference

18. Air Transportation system Aircrafts –Helicopter emergency medical service - HEMS EC 135, Sea King –Air Ambulance planes ”Fixed wing” Beech 200 aircrafts Bases –HEMS EC135 – 11 bases – 3 in Northern Norway Sea King – 6 bases - 2 i Northern Norway –”fixed wing ” 6 bases – 4 in Northern Norway Roughly 1/6 of all patients younger than 10 years, the majority are below 1 years of age. 100-150 patients in incubators per year

19. National helicopter emergency medical service - HEMS

20. Air ambulance bases in Northern Norway Aircraft Airports Hospitals Aircraft Airports Hospitals

21. Strategy of transportation- availability and quality Availability –Aircrafts Dependent on weather or seasonal conditions –wind, reduced visibility, freezing humidity Quality –Competent transportation team/equipment Levels of specialization »Primary - nurse anesthestist or intensive care nurse »Secondary - anesthesist –(neonatologist) »Tertiary - highly specialized team – ECMO, iNO Response time – shorter for HEMS than fixed wing Limitations – no alternative transportation on ground

22. Predictability of HEMS Air Ambulance Service, limited by geography, climate/season Haug B, Åvall A, Monsen SA, Tidsskr Nor Legeforen 2009, 29:1089 Blue bars - accepted and performed Red bars - cancelled – weather conditions Green bars – limited capacity incl no available duty time for crew HEMS is faster, but is less predictable

23. Air transport – pediatric patients 15-20 % of all air transports- most of them <1 yr of age.1% of neonates need transportation to a regional hospital Fenton et al: Arch Dis Child Fetal Neonatal Ed 2004 89 : F 412-15 Both primary referrals and transportation to a lower level of care In region Southern Norway 100-150 neonates- mostly transported in incubator –Congenital malformations –ECMOs / major lung failure/ multiple organ failure, –Prematurity

24. Bilder av helikoptere, fixed wing og Hercules med ECMO ECMO patient transported in ambulance Ambulance transported in C-130 Hercules - RNAF

25. Optimising neonatal transfer Transportation of neonates represents a clinical risk (Senthilkumar et al Arch Dis Child 2011;96 A91, Berge et al Acta Anaesthesiol Scand 2005;49:999-1003) –Normothermia –Normal pH –Normoventilation Transportation of premature infants increases risk of cerebral hemorrhage ( Arch Dis Child Fetal Neonatal Ed 2010 95:F403-7)

26. People seem to accept that to stay or settle down in remote areas represents a positive quality of life, but also includes a minor medical risk for them and their children. The glaciers at Galdhøpiggen 2469 m, the highest peak of Norway. From the summit in June

27. Thank You for Your attention !