Oktoberfest typically attracts 390,000 visitors a day over 17 days and poses serious challenges for local emergency medical services (EMS) due to the high incidence of injuries and intoxication, joint first authors Dr. Wilhelm Flatz, a radiologist at the Ludwig Maximilian University Hospital, and Dr. Dominik Hinzmann, of EMS authorities Munich and Technical University Munich, wrote in a letter to the editor published in the NEJM on 14 September.
This situation prompted the event organizers to install a Siemens mobile CT scanner operated by experienced technicians and radiologists in 2022. The machine was up and running from 6 p.m. to 2 a.m. local time between Monday and Friday and from noon to 2 a.m. between Friday and Sunday.
"An algorithmic approach developed in Germany on the basis of the New Orleans and NEXUS criteria for head and spine CT was implemented by paramedics and emergency physicians onsite to guide referral of persons with mild traumatic brain injury for CT," the authors noted.
Trauma-surgical hospital admissions stratified according to period. Table courtesy of NEJM.
A total of 205 patients with presumed or observed mild traumatic brain injury underwent 317 scans: 191 of the cranium, 67 of the midface, and 59 of the cervical spine. Of these patients, 11 had intracranial bleeding, 23 had midface fractures, and none had cervical spine injuries. The mean Glasgow Coma Scale (GCS) score -- ranging from three to 15, with lower scores indicating worse neurologic status -- was approximately 14 in patients with and patients without intracranial bleeding.
After CT evaluation, 17 of the 205 patients were referred to a hospital owing to CT findings; an additional 14 patients were referred for reasons unrelated to traumatic injury (e.g., insufficient "sobering up" or persistently poor GCS scores), Flatz and Hinzmann explained.
At Munich Oktoberfests held between 2015 and 2019, the mean number of patients who were taken to local hospitals by EMS and admitted for surgically treated injuries was 69.1 per day (95% confidence interval [CI], 64.3 to 73.9). This compared with 62 per day (95% CI, 52.9 to 71.1) during the period when CT was available onsite in 2022.
"When the data for weekdays and days with the highest attendance (Friday and Saturday) were compared according to period (2015-2019 and 2022), we found fewer mean daily regional trauma-surgical admissions in 2022 for both weekdays and high-attendance days," the authors wrote. "In contrast, there was little difference between the mean number of hospital admissions in the combined 16 days before and after Oktoberfest and the periods when the festival was ongoing during 2015 through 2019 and 2022."
Other data show that approximately 18% of trauma-surgical admissions to emergency departments in Munich are for head, neck, or facial trauma, and the team uses these data as a surrogate for the types of injuries in patients who would be referred because of abnormal CT scans at Oktoberfest.
Authors' reflections and plans for 2023
It is important to note that during the 2022 festival, there were a relatively high number of remaining COVID-19 cases and the state of emergency in Bavaria was still in effect, Prof. Dr. Viktoria Bogner-Flatz (EMS authorities Munich and Ludwig Maximilian University), Dr. Wilhelm Flatz, and Dr. Dominik Hinzmann told AuntMinnieEurope.com.
"The festival had already been canceled in both 2020 and 2021 due to the pandemic. Given these circumstances, our primary objective was to alleviate the strain on emergency healthcare services, including EMS and emergency hospitals. To achieve this, we made the strategic decision to position the mobile CT scanner directly in the festival grounds. Our aim was to facilitate the continuation of the festival while prioritizing safety for all attendees," they explained.
The mobile scanning facility at Oktoberfest. From the left: Dr. Wilhelm Flatz, Prof. Dr. Viktoria Bogner-Flatz, and Dr. Dominik Hinzmann.
Based on the success of last year, the city of Munich has deployed the mobile CT scanner at this year's festival, which runs from 16 September to 3 October. The scheme is being organized in cooperation with Ludwig Maximilian University -- Radiology (Director Prof. J. Ricke) and Aicher ambulance service.
"We have not made significant alterations to our protocols," the authors noted. "The scanner continues to be employed primarily for the diagnostic evaluation of injuries that have a high likelihood of patients being released onsite."
Their current focus is on the data analysis for this year's festival. "We are experiencing a 'normal' Oktoberfest, and we are keenly interested in understanding the impact on patient care at the scene as well as the effect on the broader emergency medical infrastructure under normal conditions. Therefore, the comparison between last year and this year holds great significance for our study. Additionally, we are evaluating AI technologies for diagnostics."
You can read the NEJM letter here. Also, the full paper is currently under submission elsewhere and the authors anticipate further publications on the subject of AI in this context.
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