Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

ORIGINAL RESEARCH Open Access Physician-s a ed helicop e eme gency medical se ice has a bene icial impac on he incidence o p ehospi al hypoxia and secu ed ai ways on pa ien s wi h se e e auma ic b ain inju y Toni Pakkanen 1,2* , An i Kämä äinen 3 , Heini Huh ala 4 , Tom Sil as 5 , Jouni Nu mi 6 , Ilkka Vi kkunen 1 and A i Yli-Hankala 2,7 Abs ac Backg ound: A e auma ic b ain inju y (TBI), hypo ension, hypoxia and hype capnia ha e been shown o esul in seconda y b ain inju y ha can lead o inc eased mo ali y and disabili y. E ec i e p ehospi al assessmen and ea men by eme gency medical se ice (EMS) is conside ed essen ial o a ou able ou come. The aim o his s udy was o e alua e he e ec o a physician-s a ed helicop e eme gency medical se ice (HEMS) in he ea men o TBI pa ien s. Me hods: This was a e ospec i e coho s udy. P ehospi al da a om wo pe iods we e collec ed: be o e (EMS g oup) and a e (HEMS g oup) he implemen a ion o a physician-s a ed HEMS. Unconscious p ehospi al pa ien s due o se e e TBI we e included in he s udy. Unconsciousness was de ined as a Glasgow coma scale (GCS) sco e ≤8 and was documen ed ei he on-scene, du ing anspo a ion o by an on-call neu osu geon on hospi al admission. Modi ied Glasgow Ou come Sco e (GOS) was used o assessmen o six-mon h neu ological ou come and good neu ological ou come was de ined as GOS 4–5. Resul s: Da a om 181 pa ien s in he EMS g oup and 85 pa ien s in he HEMS g oup we e a ailable o neu ological ou come analyses. The baseline cha ac e is ics and he i s eco ded i al signs o he wo coho s we e simila . Good neu ological ou come was mo e equen in he HEMS g oup; 42% o he HEMS managed pa ien s and 28% (p= 0.022) o he EMS managed pa ien s had a good neu ological eco e y. The ai way was mo e equen ly secu ed in he HEMS g oup (p< 0.001). On a i al a he eme gency depa men , he pa ien s in he HEMS g oup we e less o en hypoxic (p= 0.024). In uni a ia e analysis HEMS pe iod, lowe age and secu ed ai way we e associa ed wi h good neu ological ou come. Conclusion: The in oduc ion o a physician-s a ed HEMS uni esul ed in dec eased incidence o p ehospi al hypoxia and inc eased he numbe o secu ed ai ways. This may ha e con ibu ed o he obse ed imp o ed neu ological ou come du ing he HEMS pe iod. T ial egis a ion: ClinicalT ials.go IDNCT02659046. Regis e ed Janua y 15 h, 2016. Keywo ds: P ehospi al eme gency ca e (MeSH), Eme gency medical se ices (MeSH), C i ical ca e (MeSH), T auma ic b ain inju y (MeSH), Ai way managemen (MeSH), Endo acheal in uba ion (MeSH), Pa ien ou come assessmen (MeSH), Glasgow ou come scale (MeSH) * Co espondence: [email p o ec ed] 1 FinnHEMS L d, Resea ch and De elopmen Uni , Van aa, Finland 2 Depa men o Anaes hesia, Tampe e Uni e si y Hospi al, Tampe e, Finland Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 DOI 10.1186/s13049-017-0438-1 In oduc ion A e auma ic b ain inju y (TBI), hypo ension, hypoxia and hype capnia ha e been shown o esul in seconda y b ain inju y ha can lead o inc eased mo ali y and dis- abili y [1]. As he p ognosis o pa ien s wi h se e e TBI and a low Glasgow Coma Scale (GCS) sco e depends on ea ly suppo o i al unc ions [2, 3], e ec i e p ehospi- al assessmen and ea men is conside ed essen ial o a ou able ou come [4]. In pa icula , p ehospi al p e- en ion o hypoxia by adequa e ai way and espi a o y managemen including a secu ed ai way, no mo en ila- ion and p e en ion o aspi a ion is s ongly associa ed wi h imp o ed ou come [5–8]. Depending on he s uc u e o he eme gency medical se ice (EMS) sys em he le el o a ailable ea men a ies, and his may ha e an impac on he pa ien ’s ou - come. A sys ema ic e iew om 2009 e ealed only a ew con olled s udies examining he e ec o ad anced in e en ions by a p ehospi al EMS physician on ou - come. Inc eased su i al was ound in majo auma pa- ien s and in pa ien s wi h ca diac a es [9]. Al hough a Helicop e Eme gency Medical Se ice (HEMS) is a pa o he p ehospi al auma sys em in many coun ies, HEMS and he possible impac i has on ou come in auma ically inju ed pa ien s emains a subjec o deba e. S udies ha e been pe o med wi h he aim o e alua e he e ec o HEMS on ou come in auma pa ien s, wi h con adic o y esul s [10–15]. Di - e ences in HEMS eam composi ion, dispa ch p o ocols, EMS o ganisa ion, hospi al ea men and me hodology and ou come measu es make compa isons be ween s udies di icul . The aim o his s udy was o e alua e he e ec o a physician-s a ed HEMS in he ea men o TBI pa- ien s. The hypo hesis was ha implemen a ion o a physician-s a ed HEMS would ha e a posi i e e ec on ou come. Ma e ial and me hods The Pi kanmaa dis ic has he second la ges popula ion in Finland, wi h app oxima ely a hal million inhabi an s li ing in he ci y o Tampe e and in he su ounding mu- nicipali ies. All TBI pa ien s in he s udy egion a e admi - ed o Tampe e Uni e si y Hospi al, which is he e e al cen e in he a ea, and p o ides immedia e neu osu gical ca e acco ding o na ional guidelines ( he i s edi ion published in 2003, wi h an upda e in 2008) [16]. Pe iod 1 (2005–2010): Pa amedic EMS (EMS g oup) The EMS was he esponsibili y o and o ganised by each o he municipali ies in he egion. The sys em was wo- ie ed, wi h eme gency medical echnician basic li e suppo and pa amedic ad anced li e suppo uni s. The e we e no dedica ed on-call EMS medical di ec o s, and no physician-s a ed EMS uni s a ailable on-scene. P ehospi al c ews consul ed on-call hospi al and local p ima y ca e physicians o ea men guidelines when deemed necessa y. Pa ien s wi h a dec eased le el o consciousness we e ou inely adminis e ed oxygen ac- co ding o na ional guidelines and en ila ion was assis ed wi h bag- al e mask i equi ed. Endo acheal in uba ion was p ima ily pe o med in ca diac a es pa- ien s and in equen ly in pa ien s wi h a dec eased le el o consciousness. Hypno ics o neu omuscula blocking agen s we e no a ailable in he p ehospi al se ing and endo acheal in uba ion was pe o med using seda i es and opioids only, a he disc e ion o he pa amedic on he scene. Pe iod 2 (2012–2015): Physician-s a ed HEMS (HEMS g oup) A physician-s a ed HEMS was in oduced in o he EMS in he au umn o 2011, co e ing all municipali ies in he s udy a ea. The HEMS is dispa ched on p ima y missions oge he wi h basic o ad anced li e suppo EMS uni s o pa ien s wi h po en ial majo auma o o he c i ical medical condi ion. The ole o he helicop e is p ima ily o anspo he physician o he scene, while pa ien anspo is mainly ca ied ou by EMS g ound ehicles wi h he physician esco ing he pa ien o he eme gency depa men (ED) when necessa y. The physicians a e anaes hesiologis s expe ienced in p ehospi al c i ical eme gency medicine and conduc ad anced ai way man- agemen acco ding o he HEMS uni TBI s anda d ope - a ion p ocedu e (SOP). Gene al anaes hesia complying wi h he p inciples o neu oanaes hesia, including hyp- no ics, opioids and neu omuscula blocking agen s, is ou- inely used o apid sequence in uba ion (RSI). Capnog aphy-assis ed con olled en ila ion, in asi e haemodynamic moni o ing wi h a e ial blood gas sam- pling and, i necessa y, no ad enaline-in usion and hype - onic saline a e also ou inely employed acco ding o he uni ’s TBI SOP and na ional guidelines [16]. S udy design This e ospec i e coho s udy compa es he ou come o pa ien s wi h se e e TBI. P ehospi al da a om wo pe- iods we e collec ed: be o e (EMS g oup) and a e (HEMS g oup) he implemen a ion o he HEMS. Da a o he EMS g oup ha e been p esen ed in a p e ious s udy [10] compa ing he ou come o TBI pa ien s in wo di e - en ly s uc u ed EMS sys ems and we e used as a his o - ical con ol coho in he cu en s udy. As he physician- s a ed HEMS was in oduced in he au umn o 2011, ha yea was excluded om da a collec ing. Unconscious p ehospi al pa ien s due o se e e TBI we e included in he s udy. Unconsciousness was de- ined as a Glasgow coma scale (GCS) sco e ≤8 [17] and Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 2 o 7 was documen ed ei he on-scene, du ing anspo a ion o by an on-call neu osu geon on hospi al admission. The ICD-10 hospi al discha ge diagnoses o auma ic b ain inju y and/o skull ac u e (S06.2-S06.6, S06.8, S02.1) we e used o iden i y he pa ien s, and hei pa- ien eco ds we e c oss- e e enced wi h EMS and HEMS un-shee s. Pa ien s wi h concomi an mul iple inju ies wi h he need o o he han neu osu gical in e - en ions we e excluded, as we e pa ien s ans e ed om o he hospi als. Da a collec ed included age, gende , mechanism o in- ju y, GCS sco e and i al signs on-scene and on a i al a he ED, ai way managemen , esponse and o al mis- sion imes. Hypoxia was de ined as an SpO 2 below 90% and hypo ension was de ined as a sys olic blood p essu e (SBP) below 90 mmHg. These de ini ions a e consis en wi h he la es edi ion o he B ain T auma Founda ion’s guidelines o p ehospi al managemen o auma ic b ain inju y [1]. Fo assessmen o neu ological ou come, a modi ied six-mon h Glasgow Ou come Sco e (GOS) was used [18, 19]. A GOS o 1 deno ed dea h wi hin six mon hs, GOS 2–3 poo neu ological ou come (need o assis ance in ac i i ies o daily li ing) and GOS 4–5good neu ological eco e y (independen li e). Ou come e alua ion was pe o med, o ime o dea h was ob- ained, by he co esponding au ho , based on hospi al pa ien eco ds six mon hs a e he inciden . I he ou - come e alua ion was unclea , he esea ch eam mem- be s e iewed he case and a join decision was made. S a is ical analyses Resul s a e exp essed as medians wi h anges o pe cen - ages. The g oups we e compa ed using he chi-squa e o Fishe ’s exac es o ca ego ical a iables. Six-mon h su i al is p esen ed wi h Kaplan-Meie cu es. Com- pa ison be ween EMS and HEMS was made wi h he log- ank es . Bina y logis ic eg ession analysis was used o p edic good ou come. Va iables o he uni a ia e analysis wi h p< 0.05 we e added o he mul i a iable analysis. S a is- ical signi icance was conside ed a a p- alue less han 0.05. The da a we e analysed using IBM SPSS S a is ics o Windows Ve sion 21.0. A monk, NY: IBM Co p. e- leased 2012. Resul s Du ing he s udy pe iod (Pe iods 1 + 2) da a om 181 pa ien s in he EMS g oup and 85 pa ien s in he HEMS g oup we e a ailable o neu ological ou come analyses (Fig. 1). The baseline cha ac e is ics and he i s e- co ded i al signs o he wo coho s we e simila and a e p esen ed in Table 1. Fig. 1 Flow-cha Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 3 o 7 Good neu ological ou come was mo e equen in he HEMS g oup; 42% o he HEMS managed pa ien s and 28% (p= 0.022) o he EMS managed pa ien s had a good neu ological eco e y (GOS 4–5), li ing an inde- penden li e six mon hs a e he inciden . The e was a end o highe su i al (53% s. 43%, Log Rank p= 0.066) in he HEMS g oup du ing he 6-mon h ollow-up pe iod, p esen ed as Kaplan-Meie cu es in Fig. 2. A p ehospi al decision no o ea was done by he a ending HEMS physician on wo pa ien s. A sub- g oup Kaplan-Meie analysis wi h hese wo pa ien s e- mo ed om he HEMS g oup esul ed in highe su i al (p= 0.045). The logis ic eg ession analysis is p esen ed in Table 2. The ai way was secu ed mo e equen ly in he HEMS g oup (p< 0.001). Due o long dis ances, 10 pa ien s we e ai anspo ed o he ED in he HEMS g oup, while pa ien anspo was mainly ca ied ou by EMS g ound ehicles wi h he physician esco ing he pa ien . On a i al a he ED, pa ien s in he HEMS g oup we e less o en hypoxic (p= 0.024). In uni a ia e analysis HEMS-pe iod, lowe age and secu ed ai way we e Table 1 Baseline cha ac e is ics Pe iod 1: EMS Pe iod 2: HEMS n= 181 n= 85 p- alue Age, yea s (Median, Q 1 -Q 3 )54 33–69 53 23–74 0.479 Gende , male (n, %) 127 70 58 68 0.820 Mechanism o inju y (n, %) 0.288 Fall om g ound le el 79 43 32 38 T a ic acciden 41 23 29 34 Fall om a heigh (> 2 m) 25 14 9 11 Violence 14 8 6 7 O he 4 2 4 5 Unknown 18 10 5 6 P ima y GCS (Median, Q 1 -Q 3 )5 3–75 3–7 0.956 P ima y i al pa ame e s (n/ o al, %) Hypoxia 32/170 19 18/84 21 0.369 Hypo ension 7/174 4 4/84 5 0.514 Ai way secu ed (n, %) 29 16 81 95 < 0.001 P ehospi al decision no o ea ––22 Vi al pa ame e s on a i al a he ED (n/ o al, %) Hypoxia 18/173 10 2/84 2 0.024 Hypo ension 7/179 4 4/85 5 0.750 Mission ela ed imes, minu es (Median, Range) F om dispa ch o a i al on-scene 1s EMS Uni on-scene 8 0–37 12 4–41 0.006 HEMS ––23 6–85 To al mission ime 54 18–180 82 30–201 < 0.001 Fig. 2 Six-mon h su i al acco ding o EMS sys em (Log Rank p= 0.066) Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 4 o 7 associa ed wi h good neu ological ou come. In mul i a i- able analysis lowe age emained as a signi ican ac o o good ou come. Discussion The in oduc ion o a physician-s a ed HEMS uni sig- ni ican ly dec eased he p opo ion o hypoxic TBI pa- ien s and inc eased he numbe o pa ien s wi h secu ed ai ways on hospi al admission. This may ha e con ibu ed o he obse ed imp o ed neu ological ou - come du ing he HEMS pe iod. This suppo s ou p e ious indings when e alua ing mo ali y and neu ological ou come o TBI pa ien s in wo egions wi h di e en ly s uc u ed EMS sys ems [10]. The baseline cha ac e is ics o he wo coho s we e simila , wi h no di e ences be ween he g oups ega d- ing gende , mechanism o inju y o ini ial GCS. Only he mission- ela ed ime ames di e ed, since he esponse ime and delay o hospi al admission we e longe in he HEMS g oup. In he HEMS g oup 10 pa ien s we e ai anspo ed o he ED, bu as he o al mission imes in he HEMS g oup we e longe , his esul in ou opinion excludes he impac o he ai anspo i sel . The p inciples o p ehospi al ai way managemen o TBI pa ien s a e desc ibed in in e na ional guidelines: an ai way should be es ablished in pa ien s who ha e se e e TBI (GCS ≤8), who a e unable o main ain an adequa e ai way o who a e hypoxaemic despi e supplemen al oxygen [1]. The op imal way o secu e he ai way s ill e- mains con o e sial [20, 21]. Wi h endo acheal in ub- a ion, i RSI is pe o med poo ly, hypoxia and hypo ension ha e been shown o ha e a nega i e e ec on ou come o TBI pa ien s [21–23]. In he p esen s udy, i ually all pa ien s we e in uba ed in he p ehospi al se ing in he physician-s a ed HEMS g oup, whe eas only a ew pa ien s we e in uba ed in he pa amedic EMS g oup. In uni a ia e analysis o he HEMS-pe iod, secu ing he ai way was associa ed wi h good neu ological ou come. Anaes he ics we e used by he HEMS physicians, while he pa amedics we e limi ed o he use o seda i es and opioids. This may ha e in luenced on he obse ed di e - ence in he a e o ai way managemen p ocedu es du ing he wo pe iods. Table 2 Uni a ia e and mul i a iable logis ic eg ession o six-mon h good ou come p edic o s Uni a ia e Mul i a iable OR 95% CI p- alue OR 95% CI p- alue Pe iod HEMS 1.87 1.09–3.21 0.022 2.46 0.89–6.84 0.083 EMS 1 Age 0.95 0.93–0.96 < 0.001 0.95 0.93–0.96 < 0.001 Sex Male 1.78 0.99–3.19 0.055 No en e ed Female 1 GCS 1.07 0.97–1.18 0.183 No en e ed Hypoxia On-scene 1 No en e ed No p esen 1.65 0.81–3.37 0.165 Hypo ension On-scene 1 No en e ed No p esen 2.26 0.48–10.72 0.303 Ai way Secu ed 1.89 1.12–3.19 0.017 0.71 0.27–1.88 0.486 No secu ed 1 Hypoxia A ER 1 No en e ed No p esen 2.12 0.69–6.54 0.193 Hypo ension A ER 1 No en e ed No p esen 2.28 0.48–10.78 0.299 Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 5 o 7 In p e ious s udies bo h hypoxaemia and hypo ension ha e been shown o ha e a nega i e impac on TBI ou - come [2, 5]. We ound no di e ence in he on-scene oc- cu ence o dis u bances o hese i al signs be ween he s udy g oups. The p opo ion o hypo ensi e pa ien s on a i al o he ED was simila in bo h g oups. Howe e , hypoxia was mo e common in he pa ien s managed by he pa amedic EMS. The likely explana ion o his ind- ing is he highe equency o p ehospi al endo acheal in uba ion, con olled en ila ion and mo e p ecise and in asi e moni o ing o he i al signs in he HEMS g oup. Age has been demons a ed o be an impo an p e- dic o o ou come a e head inju y. Olde age has been shown o be an independen isk ac o o highe mo - ali y and poo unc ional ou come in TBI [24, 25]. In his s udy, in uni- and mul i a ia e analysis o he HEMS-pe iod lowe age was associa ed wi h good neu ological ou come. S udy limi a ions This was a e ospec i e obse a ional s udy and he ol- lowing limi a ions should be conside ed when in e p e - ing he esul s. The p ehospi al da a we e o iginally sel - epo ed, could no be independen ly e i ied, and could he e o e ha e been biased. Con inuous da a on i al signs co e ing he whole p ehospi al phase we e no a ailable; he e o e, sho -li ed hypoxia o hypo ension du ing he p ehospi al pe iod canno wi h ce ain y be excluded du ing ei he pe iod. Due o he low a e o endo acheal in uba ion in he pa amedic EMS g oup, pa ame e s ega ding en ila ion could no be compa ed. The i s CT scans we e no e alua ed using he Ma - shall classi ica ion. Neu osu gical and in ensi e ca e ha e ad anced du ing he s udy pe iod, which may also ha e a ec ed he esul s and may o some ex en ac- coun o he imp o ed ou come. Ou come e alua ion was based on pa ien eco d assessmen wi hou clinical examina ion o he help o a ques ionnai e. I is possible ha he dea hs occu ing in he la e s ages o he ollow- up pe iod we e un ela ed o he p ehospi al index e en , wi h seconda y diseases o inju y being he cause. Conclusions The in oduc ion o a physician-s a ed HEMS uni e- sul ed in a bene icial impac on pa ien ca e e lec ed by a dec eased incidence o p ehospi al hypoxia and an in- c eased numbe o pa ien s wi h secu ed ai ways. This may ha e con ibu ed o he obse ed imp o ed neu o- logical ou come du ing he HEMS pe iod. Fu he p o- spec i e mul icen e s udies wi h de ailed da a a e needed o con i m he hypo hesis ha a physician- s a ed HEMS has a posi i e impac on he ou come o TBI pa ien s. Abb e ia ions ED: Eme gency Depa men ; EMS: Eme gency Medical Se ices; GCS: Glasgow Coma Scale; GOS: Glasgow Ou come Sco e; HEMS: Helicop e Eme gency Medical Se ice; RSI: Rapid Sequence In uba ion; TBI: T auma ic B ain Inju y Acknowledgemen s This s udy is dedica ed o he memo y o Janne Vi a, M.D. A ailabili y o da a and suppo ing ma e ials Please con ac au ho o da a eques s. Funding This s udy was suppo ed by a s udy g an om FinnHEMS l d, Resea ch and De elopmen Uni . Decla a ions The s udy was conduc ed in he he Pi kanmaa Hospi al Dis ic , Finland. Au ho s’con ibu ions TP: he concep and design o he s udy, acquisi ion and e alua ion o he da a and co esponding au ho . AK: he concep and design o he s udy, e alua ion o he da a and he manusc ip . HH: s a is ical analyses. TS: e alua ion o he da a and he manusc ip . JN: e alua ion o he da a and he manusc ip . IV: e alua ion o he da a and he manusc ip . AYH: e alua ion o he da a and he manusc ip . All au ho s ead and app o ed he inal manusc ip . E hics app o al and consen o pa icipa e The s udy p o ocol was app o ed by he Regional E hics Commi ee o he Pi kanmaa Hospi al Dis ic ( e e ence numbe R15158), pe mission o conduc he s udy was ob ained om he Resea ch Di ec o o Tampe e Uni e si y Hospi al and egis e ed in ClinicalT ials.go (Iden i ie NCT02659046, egis e ed Janua y 15 h 2016). Consen o publica ion No applicable. Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 FinnHEMS L d, Resea ch and De elopmen Uni , Van aa, Finland. 2 Depa men o Anaes hesia, Tampe e Uni e si y Hospi al, Tampe e, Finland. 3 Tays Eme gency Medical Se ice, FinnHEMS 30, Tampe e Uni e si y Hospi al, Tampe e, Finland. 4 Facul y o Social Sciences, Uni e si y o Tampe e, Tampe e, Finland. 5 Depa men o Anaes hesia and In ensi e Ca e, Helsinki Uni e si y Hospi al, Uni e si y o Helsinki, Helsinki, Finland. 6 Depa men o Eme gency Medicine and Se ices, Helsinki Uni e si y Hospi al and Eme gency Medicine, Uni e si y o Helsinki, Helsinki, Finland. 7 Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, Tampe e, Finland. Recei ed: 27 Ma ch 2017 Accep ed: 6 Sep embe 2017 Re e ences 1. Badja ia N, Ca ney N, C occo TJ, Falla ME, Hennes HM, Jagoda AS, e al. Guidelines o p ehospi al managemen o auma ic b ain inju y 2nd edi ion. P ehosp Eme g Ca e. 2008;12(Suppl 1):S1–52. 2. Chesnu RM, Ma shall LF, Klaube MR, Blun BA, Baldwin N, Eisenbe g HM, e al. 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