violence faced by - dräger

Dräger Review Technology for Life 2018

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räger Review

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First issue 2018 V

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Emergency Services

That’s New!Two former students invent an innovative gas detector P. 40

The Beard Must Go!Breathing apparatus wearers have to forego some fashion trends P. 22

Cast Off!New cruise ship giants are built using a modular system P. 34

When onlookers suddenly turn hostile

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6 HOSTILITY

Violence against emergency services remains a puzzle:

Why are they attacked instead of supported? It is a

vexing attitude with which many workers are nonethe-less familiar. In addition to

explanations, there are also concepts to counter it.

34 ON THE HIGH SEAS

Europe’s shipyards dominate the market when it comes to building cruise ships. A visit to Meyer Werft in Papenburg, a key player in a global market that is becoming ever more demanding.

14 LITTLE ROOM TO MANEUVER

The tracheas of newborn babies provide little room for correctly positioning the tube for the anesthetic. A major European study has now evaluated experiences in this field – and delivers some surprising insights.

Around 30,000 whiskers can be found on

the average man’s face – turn to page 22 to find out more.

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3DRÄGER REVIEW 117 | 1 / 2018

The articles in Dräger Review pro-vide information on products and their possible applications in gen-eral. They do not constitute any guarantee that a product has spe-cifi c properties or is suitable for any specifi c purpose. Specialist per-sonnel are required to make use exclusively of the skills they have acquired through their education

and training and through practical experience. The views, opinions, and statements expressed by the persons named in the texts as well as by external authors of ar-ticles do not necessarily represent those of Drägerwerk AG & Co. KGaA. Such views, opinions, and statements are solely the opinions of the people concerned.

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Not all of the products named in this magazine are available worldwide. Equipment packages can vary from country to country. We reserve the right to make changes to products. Up-to-date information is available from your Dräger representative.

Dräger Safety AG & Co. KGaA, Lübeck, manufactures the FPS 7000 (page 23), the X-am 7000 (page 36 ff.), the airplane fi re simulators (page 44 ff.), the DrugTest 5000 (page 63), and the Secor 7000 (page 68). Dräger MSI GmbH, Hagen, manufactures the X-pid 9000/9500 (page 42 ff.). Drägerwerk AG & Co. KGaA, Lübeck, man-ufactures the Zeus IE [Infi nity Empowered] (page 16), the PulmoVista 500 (page 26 ff.), and the Babyleo TN500 (page 56). Draeger Medical Systems Inc., Telford, USA, manufactures the Infi nity M540 (page 52).

P U B L I S H E R : Drägerwerk AG & Co. KGaA,Corporate Communications E D I T O R I A L A D D R E S S :Moislinger Allee 53–55, 23558 Lübeck, [email protected]

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www.draeger.com

IMPRINT4People going placesDavid Casolaro trains airport firefighters in Châteauroux; Stanisław Wojtan works as a nurse in Cracow.

6Friend or foe?Why are emergency services attacked and where does this rejection stem from?

14No child’s playA major European study has revealed that the process of anesthetizing children is more prone to complications than previously assumed.

18Sky-high risk?Devastating scenes were witnessed at the fire disaster at Grenfell Tower in London. What is the situation with fire safety in German high-rise buildings?

22Hairy mattersThe beard was previously thought to offer protection against smoke gases. Nowadays, it is banned among wearers of breathing apparatus. But is this justified?

26At a glanceElectrical impedance tomography is displaying breathing patterns on-screen.

30The trouble with germsThe risks posed by disinfectants.

32Germs in hospitalsUS researchers investigated how germs spread around a newly opened hospital.

34When the ship comes inAround a quarter of a million people visit the Ems region every year to marvel at how huge cruise ships are built.

40Entrepreneurs with a good noseTwo former students have developed a gas detector and formed a company in which Dräger has a stake.

44Fire and flame The world’s only ICAO-certified training center for plane fires is in France.

50“We bear the risk”Dräger TGM is a one-stop shop for servicing machines – like those at University Hospital Schleswig-Holstein.

54Born weighing 500 gramsParents also help to give their preterm babies a bright future in Cracow.

58On the hunt for drugs in Los AngelesLAPD trains police officers how to identify drug users.

64Hold the schnappsAnimals also drink – and occasionally get carried away.

67Our contributionProducts from Dräger found in articles in this issue.

68Secor 7000How the breathing regulator for professional divers works.

EXPERIENCE FROM AROUND THE WORLD

4

People

David Casolaro, 44, fireman and trainer at the C2FPA training center in Châteauroux, France

“I lived just 200 meters away from the fire station as a child. My cousin was a member of the voluntary fire department. I found it fascinating, and at the age of 16 I joined up. That was in Velaux, a small town in Provence. We didn’t have that many callouts. My boss used to work at the fire department in Marseille and he advised me to apply there. At the age of 22 I then joined

the Bataillon des Marins- Pompiers de Marseille. Marseille has a large old town and we were often called out to fires there. In summer I dealt with forest fires more frequently. Fires rage in natural settings in very different ways, depending on the wind and vegetation. The forest fires in the south of France were particularly bad in 1997. They burned for three days. I stayed in Marseille for almost 19 years. After that, I was at Marseille-Provence Airport and dealt with heli copter fires at Airbus Heli copters. For the past three years I have been training airport firefighters

at C2FPA. We practice on airplane fire simulators under very realistic conditions. It’s about preparing the firefighters for every possible scenario – even though there is only rarely an incident at airports. The life of a firefighter consists of several practice drills for Day X. I saw quite a few dead bodies while working in Marseille. You never get those images out of your mind. However, as a firefighter you’re not alone, but part of a team. It is important to talk to colleagues about what you have gone through. You have to get it off your chest in order to be able to carry on.”

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DRÄGER REVIEW 117 | 1 / 2018

Going Places

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5

Stanisław Wojtan, 52, head nurse in the anesthesia and intensive care department of University Hospital Cracow, Poland

“The sign on my door reads ‘Head Nurse’ so lots of people are surprised to see a man sitting here. But in this case ‘nurse’is just a job title for the very career that gives me so much pleasure. I always wanted to work in a hospital when I was young, so I went to nursing college in 1984. As a man, I was in the minority, which made me more visible, so I always had to be somewhat better! Six years later, I began working here on the ICU, because I have always been interested in anesthetics as well. We have 30 intensive care beds, six operating rooms, and nine recovery rooms. I organize the nursing team for the entiredepartment. We have 140 nurses and I have to plan the roster for 30 of them every day. Sometimes I have two cell phones to my ears at the same time and the screen in front of me, on which I can see the plans for the 12-hour shifts. Our hospital is in the center of Cracow and was thereforeupgraded in 2013 to become the central admission facility in the event of a multiplecasualty incident. That hasn’t happened yet, thank God. Not even during the visit of Pope Francis for the 31st World Youth Day in 2016, when the city welcomed more than two million visitors. The Pope even came to see us on the unit! We train for a serious incident every six months so that we are well prepared. We are also well equipped in material terms. Here in the city, we have fewer problems finding qualified staff, but it is more difficult in rural areas. That is why I am involved in training and teach at the university to get young people interested in this career. I like to unwind by skiing in the nearby mountains. On the slopes I can forget about all the stresses of the job and clear my head.”


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FOCUS SOCIETY

PAVING STONES THROWN AT PARAMEDICS AT A DEMONSTRATMEMBERS OF AN EXPECTANT MOTHER RUN RIOT IN A SWISS EMEIN VANDALISM +++ FIREFIGHTERS SIGNIFICANTLY HINDERED FRUSA AND PHYSICALLY ATTACKED +++ PARIS, VIENNA, BERLIN: P

Emergency workers from all walks of life have to endure quite a lot nowadays. They are subjected to violence on an almost daily basis. Why is this the case and where does this rejection stem from?

Text: Isabell Spilker

Friend

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It was a matter of centimeters away, although firefighter Frank Hachemer only became aware of this fact when a colleague pointed out the beer bottle that had smashed next to him. The night-time callout in a small town in Rhineland-Palatinate triggered resentment among neighbors: generators, hose connections, blue lights – sleep was disturbed, the fire-fighters were attacked. Why do some indi-viduals direct their anger at those who help people and are already working at their limit? Some hospitals in the USA are now protected by walls and checkpoints. Employees are trained in the art of de-escalation. Even in Germany, ambu lances only drive through certain areas under police protection.

Sniper shotsFor Frank Hachemer, vice president of the DFV, the association representing the interests of German firefighters, the smashed beer bottle was a wake-up call: Helpers are no longer untouchable, regard-less of whether they work for the police, voluntary fire department, professional fire department, ambulance service, or in hospitals or medical practices. Hache-mer has been a member of the voluntary fire department since he was a boy and is now trying to raise awareness of the issue through the campaign “Never Assault Helping Hands!” The group representing the interests of young police officers in Germany is also attracting attention with a

I

RATION IN COLOGNE, AMBULANCES SET ON FIRE +++ FAMILY MERGENCY DEPARTMENT. FOUL-MOUTHED TIRADES CULMINATE

D FROM DOING THEIR JOB AT A MAJOR CALLOUT IN ROCHESTER/N: POLICE OFFICERS THREATENED, SPAT AT, AND PUNCHED +++

or Foe?The police: your enemy and helper?

Heavy rioting broke out in Paris on May 1, 2017. Troublemakers threw Molotov cocktails and injured

four police officers, some of them seriously


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similar campaign: “Human too” wishes to raise awareness of the increasing violence and aggression faced by police officers.

There has been an 11 percent increase in violence perpetrated against emer-gency workers in Germany compared to last year. Over the past 12 months, there were more than 26,000 cases, with over 2,000 police officers injured, some of them seriously. Acts of aggression com-mitted against public officials and author-ities have also risen in Switzerland over the last 20 years – from 423 to 2,808 annu-ally. More public officials than ever before were attacked in Austria in 2016, with no fewer than 1,039 suffering injuries. In the USA, the number of police officers killed on duty has reached a five-year high at

Hannover: Taking photos of the emergency services at work and boasting about them on social media is now sometimes

more important than allowing the crews to work unhampered – and one aspect of the changing respect toward emergency services

135, although this figure is still below the average (151) for the last ten years. However, the number of those killed with intent is particularly alarming: Of 64 fatal shots, 21 were fired by snipers.

Not really welcomeFor her study “Violence against Emergen-cy Workers” – one of the first of its kind in Germany – the lawyer Dr. Janina Lara Dressler surveyed more than 1,600 fire-fighters and emergency workers. No few-er than 85 percent of them sensed a loss of respect for their profession. The study reveals the number of assaults is much higher than those actually reported. “For the vast majority of people, firefighters are still seen as the good guys, but there

26,000 attacks on emergency workers were recorded in Germany in 2016

Bremervörde: Following a fatal accident in July 2015, three men hamper the work of the emergency services. An alter-cation breaks out. They faced charges last year – the sentence was passed in April 2017

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Frank Hachemer, Vice President of the DFV

“It feels like it is getting worse”Mr. Hachemer, have you noticed an increasingly aggressive attitude toward firefighters?The situation in society as a whole is also evident in our line of work. The relationship between us and the people around us has changed. We are no longer protected by a natural authority. The fire department is now often viewed in the same way as the police – as a state power. Many people make no distinction here. We may be rated as the profession with the highest level of trust, but that doesn’t protect us at all.Is this development also in evidence when it comes to matters such as lanes for emergency vehicle access?This is also a problem in society. People put themselves first. Allowing emergency vehicles to get through is no longer the top priority. Instead, people want to make sure that they themselves can get away from the situation easily. Our society is increasingly concerned about focusing on one question above all else: What do I get out of it? Do you consider insults to be a form of violence or only physical altercations?There is such a thing as verbal violence. The way in which the atmosphere is handled is crucial for determining how I feel. It feels like it is getting worse; many colleagues are saying this. When onlookers used to be unceremoniously forced back, there was no complaining. Nowadays it is discussed and challenged. All of this makes for a tenser atmosphere.Are emergency workers now trained in the art of de-escalation?This is handled and accepted by colleagues in very different ways – depending on the state association. We have the “Never Assault Helping Hands!” campaign, which trains others to spread the message.

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appears to be a growing number of peo-ple who no longer see it that way,” says Dressler. “In their concept of the enemy, they classify the firefighters as ‘servants of the state’ and thus fail to recognize the intention to provide assistance.” In some situations, firefighters are virtually denied the right to bodily integrity, because they are seen as “servants of the state” in their uniform. “People seem to completely ignore the fact that more than 95 percent of firefighters in Germany work on a vol-untary basis,” stresses Frank Hachemer, “and such attacks especially affect them in particular.” Anyone who physically or verbally assaults a firefighter is in all like-lihood confronting someone who neither represents the state per se, nor receives remuneration for their service.

Hospitals also report an increase in assaults and a readiness to use violence. In addition to overworked staff, the main reason for this is often a lack of commu-nication. Those who are waiting are kept in the dark about the treatment plan and there is a failure to identify emergency cases, or the ability to do so is obscured by an individual’s own feelings. Almost a quarter of German general practitioners have experienced violence on at least one occasion. “The risk is even higher in the field of psychotherapy or psychiatry. Yet there is hostility everywhere, as reported by colleagues in other disciplines. I receive verbal abuse and threats when I have no free appointment slots or am unable to issue a certificate,” confirms Dr. Hans Ramm, neurologist and psychotherapist and board member of Hamburg’s medical council. Dr. Ellen Douglas, a consultant at

Buchholz Hospital, just outside Hamburg, says: “Even though the level of violence has not increased, we are more frequent-ly dealing with patients who do not under-stand why they have to wait. The tone then becomes more aggressive.” They view the fact they are not being immediately treat-ed as victimization. Dr. Douglas highlights a problem with which many hospitals are familiar: emergency departments over-whelmed with non-emergency cases. And it is especially those individuals who have waited weeks for an appointment with the consultant and lose their patience at the weekend who finally flip out while waiting at the hospital. The experience of Dr. Dan-iel Schachinger, medical director at the central emergency department of the

Berlin/Westend DRK Hospital, is similar, although much more conspicuous. “There has been a significant rise in the number of attacks over the past ten years. Verbal abuse, altercations, and even considerable physical violence are now a reality.”

The problem is more visibleEven though the reports and statistics are clear, many experts are playing down the issue. The German social scientist and aggression researcher Klaus Wahl speaks of subjective experiences and sees no overall social trend toward barbari-zation in the bigger historical context. “We are generally living in an ever more peaceful world – violence is steadily on the decline.” Dr. Rafael Behr, a professor of

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police science who specializes in crimi-nology and sociology at Hamburg Police Academy, also tries to reassure people: “The latest studies reveal no spectacular or overall rise in violence. The problem is merely in the public eye to a greater extent and is more visible.” The assaults involve less than one percent of all police officers. And anyone who has even suffered concus-sion and spent 24 hours under observa-tion in hospital is deemed to be seriously injured. “The latest studies show that peo-ple’s perception of violence and aggres-sion is changing,” explains the Hamburg-based police scientist. People nowadays are much more horrified and affected when confronted with aggressiveness. Media reports on such incidents increase

Rainer Wendt, President of the German police union (DPolG)

“Aggression grows out of mundane situations”Mr. Wendt, violence is directed at which members of the emergency services in particular?We are seeing an increase in violence toward all employees in public office – teachers, revenue officers, judicial officers, train guards, and police officers. There is now a readiness in society to commit acts of violence. It is terrifying: aggression grows out of mundane situations.What is the cause of this?The violence is generally not directed at individuals, but at the state. The police officer senses an increasing loss of authority as an enforcer of state authority. The state has become a service provider; the citizen a client. This was the wrong approach.How can the problem be solved?By creating a strong state! And this doesn’t mean using a firmer hand, but establishing a better democracy. The civil service must be strengthened. We need more staff. Is increasing the penalty for attacks on police officers one possible approach?It is bad when emergency workers are attacked. They deserve the protection provided by criminal law. If the law can be applied to prevent the perpetrator from getting off scot-free, then this helps, but the problem with society itself remains.

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Violence committed

against police officers is primarily aimed at the state

January 2015: The images from a surveillance camera operated by Philadelphia Police Department show a man approaching the patrol car with a gun, shooting, and subsequently fleeing the scene. The police officer was seriously injured

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SOCIETY FOCUS


sometimes projects a distorted view of this confrontation. Rainer Wendt, president of the German police union, stresses that 80 percent of attacks on police officers do not occur at demonstrations, but in the course of everyday duties. And the crim-inologist Professor Behr talks about the increasing insubordination of civil society toward the state. Firefighters, emergen-cy workers, doctors, and nurses are often placed in this very pigeonhole.

Respect thanks to fairness“Our society articulates whatever it finds displeasing and makes things difficult, which essentially isn’t wrong,” says Behr. “Many police officers, however, perceive precisely this as something stronger than resistance.” They fail to understand that the aggression is not directed at them as individuals, but at the state they rep-resent in their uniform. So is an increas-ing lack of respect the cause? It would cer-tainly explain the attacks on those who are there to help. Yet even here there is no uni-versal answer. “Fairness is the prerequi-site for respect,” stresses Behr. “Respect is not simply there, but is created in the course of social interaction.” It takes good communication. However, not every situ-ation is conducive to this: Situations such as a burning house, a serious accident, or an overcrowded emergency department require a professional approach, although there is often no time for explanations, let alone discussions. Time is tight, which can appear authoritative and contribute to the escalation of the situation. More than 60 percent of actual attacks are committed by people under the influence of alcohol.

the sense that everything is only getting worse and more brutal. “We see matters from a comparative perspective, based on the maxim that things like this nev-er used to happen. However, anyone who believes that people used to know when to stop and nobody ever kicked anyone while they were down on the ground is mistaken.” This is merely an attempt to categorize and interpret the development by means of seemingly accurate recollec-tions. In actual fact, it is often no more than astonishment at the inexplicable.

An expression of emancipationWhen acts of aggression are committed against helpers, a distinction must first be made between the violence shown toward

police officers and that shown toward other emergency services. While attacks on firefighters and other helpers can be explained by a rejection of assistance, those committed against police officers tend to be a form of rebellion against the state. It seems that the idea of respect has continually changed over the course of the years. Parents and schools teach children to meet state authority on an equal foot-ing. This is combined with a latent fury about everything that is not going well in their own lives or in the country. The state is blamed for this, which then stands in front of them in uniform – as a police officer, for example. The citizen no longer sees the officer as a fellow citizen, but as the personification of the state. The media

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Two firefighters died in 2012 following a targeted attack in the US state of New York – two others were injured. The men from the West Webster Fire Department carry one of their colleagues to the grave on a fire truck

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“Alcohol is like a catalyst: It lowers peo-ple’s inhibitions, eliminates control mech-anisms, and amplifies existing behavior-al tendencies,” says social scientist Wahl. Those with a proclivity for violence will find it more difficult to control themselves under the influence of alcohol.

A growing level of brutalityThe proclivity for violence is determined by a number of factors. Some are biolog-ical, such as sensitivity or temperament. Learned elements have an even greater impact. “Violence is generally learned violence,” says Dr. Ulrich Wagner, profes-sor of social psychology at the University of Marburg. “We learn from others how to commit it and use it successfully.” Yet frustration, dissatisfaction, and the inabil-ity to solve conflicts can also lead to vio-lent behavior. Aggressive tendencies are particularly striking and have their own

distinct dynamism in groups. “Being part of a group leads to the disparagement of others who are not part of it,” says Wag-ner. “This goes as far as a dehumaniza-tion of outsiders.” Above all else, this dis-paragement explains many of the acts of violence – on both sides. After all, the same behavior pattern based on group dynamics is present among the police. “You see the opposite side committing assaults on your own group,” says Wagner. “This increas-es the readiness to reciprocate with coun-ter-violence.” This is also the reason why the ban on obscuring the face is a good idea, because anonymity in a crowd only increases the readiness to commit vio-lence of this kind. And yet it is frequent-ly individuals who turn into perpetra-tors and throw bottles, smash equipment, and harass care staff; individual, aggres-sive perpetrators who are not under the influence of alcohol, are not affiliated to

Criminal damage: In Bergisch Gladbach an emergency vehicle was stolen and smashed up during a callout

Being part of a group

leads to the disparagement

of others

People often take out their built-up rage on the emergency services. A patient with two painful legs in plaster in the Austrian city of Wels even assaulted a paramedic because a hospital refused to admit him

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The theologian, emergency psychologist, and paramedic Michael Steil is an author and the founder of the psychosocial emergency care network

“People vent their anger”Mr. Steil, was it easier to save people’s lives 20 years ago?Standards are higher nowadays at least. Not only in terms of quality management, but also the emergency services themselves. We live in a society with a patient-centered mentality: There is a solution to everything. And if there is no solution, then people vent their anger – even against the emergency services if necessary.Does that apply to all social strata?This behavior can be seen across all social strata. In the battle to get the best photo, for example (in keeping with the maxim of being in the thick of it rather than merely being there), the work of the emergency services is sometimes completely ignored and occasionally even hampered or denigrated. Yet in the statistics for the various professions, the emergency paramedic is a well-regarded profession!That may well be true, but in reality the paramedics have less and less time to cover ever greater distances. Our security needs run counter to the reality of medical care, leading to frustration among the patients.

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any group, and have no preexisting men-tal illness. The conflict researcher Pro-fessor Klaus Wahl explains the possible development of this aggression as a com-bination of thoughts and feelings: “These people with an oversensitive social radar find themselves in a world of enemies. At least that is their subjective impression.” Remarkably often, they have a distorted perception of the feelings and behavior patterns of others – and interpret normal behavior as provocative, threatening, or aggressive toward them. They often have a tendency to defend themselves and pre-empt such perceived behavior by commit-ting their own acts of violence. In contrast to his colleagues, Professor Wagner sees a rise in the severity of assaults. “For quite some time, there appears to have been a growing level of brutality among some per-petrators,” he says, albeit rather cautious-ly. From a psychological perspective, this may be due to two reasons: a high degree of excitability, and the learning of vio-lence. “Watching violent media and play-ing aggressive computer games increases the propensity for aggression. That is sci-entifically proven.” People then tend not only to be prepared to react with aggres-sion; it also influences the way in which they react. “The human being is a learn-ing creature.”

Everyone seeks their own solutions. While firefighters work on their image as helpers, the updated sentencing guide-lines recently passed in Germany promise more severe consequences for those who attack police officers. Both doctors and other emergency workers feel aggrieved. Social scientist Wagner views this not

uncritically: “What kind of signal does it send out when assaults on one profession are penalized more heavily than those on another?” Ways of equipping people with efficient de-escalation strategies as well as staff with strong communica-tion skills appear to be more promising approaches. Modern emergency depart-ments have recognized the problem and are responding to it with large, open-plan waiting areas and transparent admission and treatment procedures. Fire depart-ments and other emergency services have also been helped more by increased staff-ing levels, shorter waiting times, and training than by harsher pe nalties for per-petrators of violence. Dealing with one another in a respectful manner is a two-way street. “In most cases, the conflicts themselves aren’t the problem, but rath-er the lack of ability to solve them,” says Wagner.

LITERATUREPatricia Blumenreich and Susan Lewis: Managing The Violent Patient: A Clinician’s Guide, Routledge

Georges Steffgen: Emotions and Aggressive Behavior, Hogrefe & Huber Pu

Daniel J. Flannery, Alexander T. Vazsonyi:The Cambridge Handbook of Violent Behavior and Aggression, Cambridge University Press

INTERNETwww.who.int/violenceprevention/approach/definition/en/

www.preventionresearch.org

“MOST ARE STRESSED”Dr. Daniel Schachinger, medical director in Berlin, on aggressive patients, appropriate de-escalation measures, and the power of reflection. www.draeger.com/117-13

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Children are not simply small grown-ups. This is also the case in the field of medicine. One major European study has revealed that the process of ANESTHETIZING them is more prone to complications than previously assumed, underlining how important a longer period of training is in this difficult field.

Text: Dr. Hildegard Kaulen Photos: Patrick OhligschlägerNo Child’s Play


HOSPITAL ANESTHETICS

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It is sometimes the small things that present the biggest chal-lenges: the trachea of a newborn baby is just four centimeters long and has a diameter of four millimeters. There is no more room to maneuver when it comes to correctly positioning the tube during an anesthetic. What’s more, the airways of a new-born baby are not very strong due to the untrained supporting and respiratory muscles. The rib cage is elastic and paradoxical movements can give the impression that the lungs are being ven-tilated even when this isn’t the case at all. Also unusual is the fact that the narrowest point in the airways is not located in the glottis – as is the case in adults – but further down. In addition, children need approximately twice as much oxygen per kilogram of body weight as adults, because they have a higher basal met-abolic rate. When they breathe out, only a little oxygen remains in the lungs. As such, newborn babies and infants soon have dif-ficulty breathing if the air supply fails to materialize. The conse-quences are manifold and can lead to cardiac arrest.

There is often a lack of intuition with childrenDr. Jost Kaufmann is familiar with these challenges. He has been senior physician at Amsterdamer Straße Children’s Hospital in Cologne since 2009. The anesthesiologist and pediatric consul-tant is also an emergency baby doctor. The department is head-ed by Professor Frank Wappler, who is currently chair of Anes-thesiology II at Witten/Herdecke University. So what actually makes pediatric anesthesia so prone to complications? “Noth-ing is standard with children, particularly those under the age of three,” says Kaufmann. “This starts with the specific anatom-ical and physiological features and ends with the dosing of anes-thetic and drugs, which have to be individually calculated and set in proportion to the body weight,” he says. “To this end, the body weight must be reliably determined and recorded. Anesthe-tists are usually less familiar with these kinds of doses, because they generally only seldom anesthetize children, unless they work in a specialized center,” says the senior physician. “Many col-leagues lack the intuition to tell whether their calculations are

I

Keeping an eye on everything: Anesthetist Katrin Bode, nurse Ariane Habor, and senior physician Dr. Jost Kaufmann (from l. to r.) monitor the vital data of their small patient. Tigger can stay with him, although he has to wait for his friend

DRÄGER REVIEW 117 | 1/ 2018 15

Full of anxiety: With Tigger by his side, this small baby waits for his

anesthetic. The anxiety is etched on his face

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16 DRÄGER REVIEW 117 | 1 / 2018

right or wrong. Depending on the drug administered, a miscal-culation on the scale of a power of ten can considerably endan-ger the life and health of a child.

Complications in one in 20 anesthetized childrenA study published in the renowned journal The Lancet Respira-tory Medicine has been the subject of much conversation since the spring of 2017. APRICOT* provides an insight into the state of pediatric anesthetics in Europe as well as the nature and fre-quency of major complications. With 261 hospitals taking part from 33 countries and a total of 31,127 anesthetic procedures evaluated, it represents Europe’s biggest database to date. Profes-sor Wappler’s department was involved in the collection of data along with 27 other German centers. Over a two-week period, the hospitals were asked to report all major complications aris-ing from routine or emergency procedures carried out on chil-dren of all ages. Major complications included any events that required immediate intervention in order to prevent the chil-dren coming to harm.

According to the data collected, major complications occurred in one in 20 anesthetized children. Among the most common were obstruction of the larynx and cramps in the bron-chial muscles. Both prevent ventilation of the lungs and soon lead to a lack of oxygen in small children. Nine children suf-fered a cardiac arrest and had to be resuscitated. Those at most risk were very small and sick children and those with preexist-ing high-risk illnesses. The study also revealed big differences between the individual European countries. Some reported 20 to 30 times more major complications. It also showed that every additional year of experience in the field of pediatric anesthetics reduced the risk of major complications by one percent. In oth-er words, anyone who anesthetizes a high number of children clearly makes fewer mistakes. One major plus of the study is its sheer size. Never before have so many countries, centers, and hospitals been involved in a survey of this kind. However, there are also points of criticism. One relates to the study design. The anesthetists themselves reported the incidents after the proce-dures, together with their personal identification number. This made it possible to assign the reports to individuals. It would have been more objective to let external monitors inspect the

Even a small miscalculation can endanger life

Everything is so different: The

environment, the clothing, and only

the eyes of the nurse anesthetist can be seen. How

must the little patient feel?

Fragile being: Everything is small on babies: the body, the airways, the blood vessels. It takes experience to anesthetize them, as seen here at Amsterdamer Straße Children’s Hospital in Co-logne, using the Dräger Zeus IE

Experience counts: A well-rehearsed team is important anywhere, but especially in places where very small and sick children are operated on

* Anaesthesia Practice In Children Observational Trial

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17DRÄGER REVIEW 117 | 1/ 2018

ANESTHETICS HOSPITAL

S2e guidelines:Recommendations for drug safety in the field of pediatric anesthetics.www.draeger.com/117-17

anesthetic procedures and report the major complications. How-ever, this simply was not possible in a study of this magnitude. “When the individuals themselves submit the reports, there is always a risk that not all incidents come to light,” says Profes-sor Wappler, “either because they went completely unnoticed or because the anesthetist was reluctant to pass on the infor-mation.” Dr. Jost Kaufmann also suspected from the number of medication-related errors that probably not everything was reported. According to the data from the APRICOT study, a seri-ous drug administration error only occurred in one in 500 cases. “This does not correlate with our experiences, nor is it consis-tent with what we know from other studies.”

Quality deficiency or deficient error culture?In 2016, he and other colleagues published guidelines on drug safety in the field of pediatric anesthetics using evidence-based research. “We know from a study of adults in which external monitors reported the errors that a drug administration error occurred in one in 20 cases. Since every patient is generally giv-en ten drugs or more, a drug administration error occurred in one in two anesthetic procedures. It is hard to believe that with so many individual doses in the field of pediatric anesthetics that just one drug administration error occurred in every 500

cases.” The same applies to the obstruction of the larynx, known as laryngospasm. In the APRICOT study the frequency rate was 1.2 percent – the same as that for bronchospasm, where the bron-chial muscles are cramped. “In our experience and according to the figures published in literature, the reported rate of laryn-gospasm is surprisingly low. Laryngospasm should occur much more frequently than bronchospasm. This implies that not all cases were reported.” Also striking is the difference between the rates reported in the individual European countries, with some rates 20 to 30 times higher than others. Commenting on the study in The Lancet Respiratory Medicine, Professor Jerrold Lerman from the Women and Children’s Hospital in the Amer-ican city of Buffalo suspects the differences may be due to the quality of training and hospitals. Yet there may also be questions as to whether preexisting illnesses – which increase the risk of complications when administering an anesthetic – are treated in the same way everywhere, such as childhood asthma. However, there may also be another explanation. “Maybe our colleagues in some countries were simply more honest and really did report everything in terms of errors made,” says Dr. Kaufmann. In other words, it is possible the differences recorded between the coun-tries are a reflection of a diverging error culture rather than diverging quality.

For Professor Wappler, the APRICOT study is nonetheless an important reference framework for further quality improve-ments: “According to the study, our profession is clearly less successful than we thought. There appears to be more compli-cations with pediatric anesthetic procedures than previously assumed. As such, we have a problem we have to tackle – regard-less of how vague the results ultimately are and irrespective of how much criticism can be leveled at the study.” Wappler takes the view that the existing concepts and processes in the field of pediatric anesthetics must be challenged. “To this end, we must evaluate the data from the study even more thoroughly and exam-ine what can be resolved with new, well-defined study designs in terms of achieving the necessary precision.”

For Professor Wappler and Dr. Kaufmann, the study makes the case for better and longer training under supervision – especially when it involves anesthetizing children under the age of three. In some European countries, young anesthetists are overseen by experienced colleagues for a long period of time. In Germany, just one anesthetist is generally present in the operating room. “We would be well advised to adapt our training and profession-al development measures to match the opportunities and con-ditions of other European countries,” says Wappler. The authors of the APRICOT study also see an urgent need for standardized training and rules that apply throughout Europe.

He knows what’s important:Professor Frank Wappler, senior physician in the pediatric anesthesiology department

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PANORAMA FIRE PROTECTION

The FIRE SAFETY REGULATIONS for German high-rise buildings are considered outstanding when compared to those of other countries. Yet is this enough? And what is the situation with buildings with an effective height of less than 22 meters?

Text: Peter Thomas

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18 DRÄGER REVIEW 117 | 1 / 2018

018_Draeger-117_EN 18 30.01.18 12:45

19

can only use non- combustible materi-al (“insulating material in non-combus-tible, enclosed profiles”) for energy-effi-cient renovations. This usually comes in the form of exterior insulation and finish systems (EIFS) made of mineral wool or mineral foam.

Is “flame-retardant” enough?Nonetheless, experts point out the poten-tial risk posed by EIFS. On June 12, 2017, the working group representing the chiefs of professional fire departments (known in Germany as the AGBF), the association representing the interests of German fire departments (the DFV), and the German Fire Protection Associa-tion (GFPA) jointly published the position

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Mainhattan: Frankfurt am Main’s nickname is based on the name of the district in New York – the numerous skyscrapers also represent a challenge for fire safety in the German city

Fire container: Working with closed-circuit breathing apparatus

Extreme need for breathing airFirefighters face extreme challenges when working in high-rise buildings. If no firefighter’s elevator is available, they have to climb the stairs in full equipment weighing 30 kilograms. “Such jobs are comparable to those in underground transport systems – here, too, the hours are long and the need for breathing air immense,” says Carsten Joester from Dräger. That is why professional fire departments responsible for such infrastructures have closed-circuit breathing apparatus. Moscow Fire Department alone – which is responsible for a subway system almost 350 kilometers long – is thought to have several thousand such units.

DRÄGER REVIEW 117 | 1/ 2018

The evacuation of more than 400 apartments in Dortmund, and the evacuation of an 11-story building in Wuppertal, fire safety officers deployed outside apartment buildings in the district of Offenbach: Fire protection in high-rise buildings led to drastic measures being taken in Germany in the summer of 2017. The general public has also asked many questions of the regulations governing the cladding that insulates façades.

This was all preceded by the devastating fire at London’s Grenfell Tower on June 14, 2017, in which dozens of people lost their lives. The fire has once again shown that

Tfire risks increase with the height of the building, because a large number of people are immediately affected in one building, while the escape routes are inherently long. Relevant building regu-lations in Germany set out very high fire safety standards for high-rise buildings. Of particular significance is the mod-el high-rise building directive (known by its German abbreviation MHHR), which prescribes a protected staircase and a firefighter’s elevator, among oth-er things. In high-rise buildings taller than 60 meters, fire alarms and extin-guishing systems (generally sprinklers) are also mandatory. There is also no compromise when it comes to the insu-lation: Buildings taller than 22 meters

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PANORAMA FIRE PROTECTION

20 DRÄGER REVIEW 117 | 1 / 2018

Floors that burn within minutes

paper “Fire Safety of Exterior Insulation and Finish Systems on Façades Using Polystyrene Foam (EPS) as the Insulat-ing Material.” The abbreviation stands for expanded polystyrene, otherwise known as Styrofoam. Such insulation materials are considered to be “flame-retardant” – they are treated with a pro-tective agent. For a long time, the chem-ical hexabromocyclododecane (HBCD) was used for this purpose, which led to considerable problems in 2016 when attempting to dispose of old insulation material. Brominated styrene butadiene copolymer ( PolyFR) is now used instead. Although these elements cannot be used on high-rise buildings (defined as having an effective area extending higher than 22 meters), there are also many build-ings below this threshold with numerous residential units.

So what happens when a fire spreads across the insulation here? The extreme-ly fast spread of fire across the façade, which has happened repeatedly with sys-tems of this kind, represents an unsolv-able problem for the fire department: With a response time of ten minutes, the fire cannot be prevented from spreading to more than two floors,” states the posi-tion paper. Experience has shown that it is also dangerous, difficult, and gen-erally impossible to save people in tall-er buildings below 22 meters when the façade is burning, according to the AKH (the chamber of architects and urban planners in the state of Hesse). This is especially the case when the second-ary escape route is provided by the fire department’s hydraulic rescue equip-ment (such as turntable ladders and telescopic masts).

It is also for this reason that in July 2017 the AKH called for polystyrene insula-tion to be banned on all buildings higher than seven meters in future (Class 4) – a subject which, according to the AKH, has been discussed for quite some time in professional circles.

The VDPM (Germany’s industry association for insulation systems, plaster, and mortar) counters that the proven and widely used insulation systems are fire-retardant and plastered over so as to be airtight. In practice,

Grenfell Tower: The particular challenges of fire safety in high-rise buildings were

also brought into the public eye in mid-2017 following the blaze in London

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Fire protection“It’s not about demonizing EIFS made of EPS.”Read the full interview here:www.draeger.com/117-21

Professor Reinhard Ries: The architect and chief of Frankfurt’s fire department has dealt with the fire risk posed by façades for a number of years

“Then things get dangerous!”Professor Reinhard Ries has been chief of Frankfurt’s professional fire department since 1993. In this role, the 61-year-old father of three is responsible for preventive fire safety in buildings in the city as well as disaster management, emergency ambulance services, and air emergencies. The architectural engineer also teaches at various universities. Ries spoke to Dräger Review about the fire risk posed by exterior insulation and finish systems.

Professor Ries, the fire at Grenfell Tower in London has also brought fire safety in high-rise buildings into the German public consciousness. Can the risk in both countries be compared at all?No, there are clear differences. As far back as the early 1980s, Germany’s high-rise building directive specified among other things that only non-combustible cladding could be used. To this day, nothing has changed in this regard. As such, high-rise buildings in Germany are generally very safe.

The regulations in Germany are generally considered to be strict, so why do fire safety experts nonetheless warn of the risk posed by insulated façades?This primarily relates to buildings taller than 22 meters, which are being clad with ever thicker exterior insulation and finish systems (EIFS) made of expanded polystyrene (EPS) on a more frequent basis. In recent years there has been something of a boom in making new and existing buildings more energy-efficient, but if these measures are not carried out correctly, then things get dangerous. Furthermore, we (the fire departments) view the inspection procedure used until now for these façades as insufficient.

What exactly is the decisive factor here?EIFS must always be reliably encapsulated so that a fire cannot spread. Fire barriers are just as important here as the correct installation of the insulating material on the main structure. Unfortunately, deregulation within the construction industry has meant that no inspection is carried out by construction supervision authorities. We know from experience that many façades are not installed correctly. There are repeatedly cases where the entire insulation has had to be taken down again, thrown away, and reinstalled following inspection by experts.

When did you start focusing on the fire risk of exterior insulation and finish systems?Two callouts proved decisive: In 2010, the insulation of a façade caught fire in a rear courtyard, ignited by a burning trash can. We had to rescue 21 people from a height of 12 meters using turntable ladders, because the stairwell was also filled with smoke. It was a very difficult job. Two years later, the 20-centimeter-thick insulation fitted on a newly renovated building more than 20 meters tall went up in flames. The fire spread across the almost completed façade from an ignited pile of insulation material on the ground and had engulfed the entire height of the building within a matter of minutes, destroying at least 36 apartments. Fortunately they were empty due to the ongoing building works.

however, they do not remain so, not least due to exterior damage caused by woodpeckers, for example. Since the beginning of 2016, it has been manda-tory to incorporate additional fireproof barriers on lower floors (on multistory buildings between seven and 22 meters tall). If cladding made from flame-retar-dant EIFS should nonetheless catch fire, the risk to all involved is quite simply sky-high.

Virtually unmanageable“The façade could deflagrate like a torch; the fire would then become virtu-ally unmanageable,” says Professor Rein-hard Ries, chief of the professional fire department in Frankfurt am Main, talk-ing about his experiences of a major fire in 2012. The subject of combustible cladding has occupied him for a num-ber of years. Ries is responsible for one of the biggest stocks of high-rise build-ings in the Main metropolis. There are several hundred high-rise buildings up to 60 meters tall and several doz-en other buildings are up to 200 meters tall. Some skyscrapers are even taller. Yet experts not only see a need for action when it comes to Class 4 buildings. It is also about managing the risks posed by existing high-rise buildings built before the current MHHR directive (published in April 2008 and updated in Febru-ary 2012). If they haven’t been renovat-ed, then the directives dating from 1983, 1973, or 1955 apply to them, depend-ing on when they were built. In addi-tion, regulations are not always observed when buildings are upgraded. “It is right that the German fire safety regulations are viewed as strict, but time and again there is evidence that they are not con-sistently observed everywhere,” says Dirk Aschenbrenner, chief of Dortmund’s pro-fessional fire department and president of the GFPA. “Older buildings in particu-lar should be regularly inspected.”

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22

Hairy

The beard has to go. There’s no getting

around it for wearers of breathing appara-tus. That’s because

the WHISKERS along the seals of their

masks create leaks – short stubble is espe-

cially risky. A visit to the barbershop is

a pleasant experience anyway.

Text and photos: Peter Thomas


By a whisker:Kostja Epp, owner of a

barbershop in Offenbach, shaves in the classic

fashion – with straight razor, foam, and a great

deal of feeling

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BREATHING APPARATUS FIREFIGHTING

23

regular resistance, not least since the so-called Hairnet Decree enacted in German federal states in the 1970s. At the begin-ning of 2017, the dispute between a district fire inspector and voluntary firefighters about their beards caused quite a stir in the media. Nonetheless, it is unlikely that the regulations will be changed anytime soon, because there are currently no fire-fighting face masks whose sealing line lies outside the face. The new ISO standard 17420 for breathing apparatus is expected to be published as an international standard in 2020. “This will also mean that wearers of breathing apparatus will have to con-tinue working without beards,” says Wolfgang Drews. The engi-neer has been involved in drawing up the standard since 2011. He says that the standard always argues from the perspective of the user who is to be protected from hazards in the workplace.And this means that the sealing line would have to run below the Adam’s apple of beard wearers, because there is generally no beard growth in the neck area. The corresponding scenarios go as far as the vision of a flame-protected and gastight chemi-cal protective suit (CPS).

The classic wet shave remains unsurpassedIn the meantime, how does a man who is not allowed to grow a beard achieve the perfectly shaved face? Among the depilation methods (this is the name given to the part of the hair removed above the skin’s surface; epilation involves the complete remov-al of the hair from the root), the classic wet shave is still unsur-passed. This is not just due to the sharpness of the blade, but also the elaborate procedure. In Kostja Epp’s Offenbach barber-shop, he has now fitted a new blade to the shavette (a straight razor with a classic folding handle). Instead of a fixed blade, the razor has a holder for disposable blades. The shavette is popu-lar with many barbers, not least for reasons of hygiene. Music

Matters


The blade glides gently across the skin; its edge is less than one micrometer (0.001 mm) thick. Stroke by stroke, it forces its way through the foam and beard. What remains is a perfect-ly shaved face – not to mention a good feeling. “The classic wet shave is wellness for the man,” says Kostja Epp. The six-foot-six giant with tattooed arms and full black beard is the owner of the Blckbrd barbershop in Offenbach am Main. His customers also come from the neighboring financial metropolis of Frankfurt. Is it not part of Frankfurt folklore to look down on Offenbach? “We may be the little brother, but we’re cooler,” says a grinning Epp. The barber industry is booming. Full beards are back in fashion. Whether sporting a ducktail, Hollywoodian, or the mighty Garibal-di, men in many places – from hip digital nomads to bankers – are adhering to the maxim that facial hair should be shown off and well groomed. In this regard, today’s urban heroes can count on the service of the same professional who traced around the chins of their great-great-grandfathers with a sharp blade: the barber.

However, wearers of breathing apparatus in fire departments and in industry have a problem with beard fashion. This is due to the fact that facial hair along the sealing contours of their breathing apparatus masks is an exclusion criterion for their use, because they can cause life-endangering leaks. Smoke gases and other hazardous substances from the outside can penetrate these gaps, or the breathing air can escape uncontrollably, reduc-ing the working time of the person breathing the compressed air. So the beard has to go, for reasons of self-protection if nothing else. In Germany, this is also laid down in Fire Service Regula-tion 7 (published in 2002 and amended in 2005): “Firefighters with beards or sideburns around the area of a face mask’s seal-ing line are unfit to wear breathing apparatus.”

This is no victimization. Instead, it serves to safeguard the firefighters and those they are rescuing. There is nonetheless

T

Dräger FPS 7000:Firemen should always

go to work clean-shaven to ensure that the full

mask on the breathing apparatus is well sealed

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FIREFIGHTING BREATHING APPARATUS

24 DRÄGER REVIEW 117 | 1 / 2018

Photo gallery: Streetwear, sharp blades, and plenty of tattoos – a visit to the Blckbrd barbershop in Offenbach.www.draeger.com/117-24

can be heard in the background that is as raw as the bare brick walls of the old building. The master lays hot compresses on the customer’s face, which has been treated with a pre-shave lotion beforehand. “This opens the pores, relaxes the skin, and softens the whiskers,” says Epp, while foaming up shaving cream and hot water in a metal bowl using a badger shaving brush. After applying the thin layer of soap, the beard stubble pokes out from beneath the white foam. He pulls the skin taut with the finger-tips on one hand while the other guides the razor with an adept stroke. All that remains is smooth skin. A soothing balsam and a cold compress are then applied. The whole procedure is over in half an hour.

34 pages on beard growth and breathing apparatusThose firefighters who treat themselves to the skills of a bar-ber are also indulging in a bit of pampering – and are doing something to ensure their own safety while on duty. Firemen should always go to work clean-shaven. Lower Saxony’s acci-dent insurance provider for firefighters also makes reference to this: Tests have revealed “discernible differences in the leak-age values between clean-shaven firefighters and those with a five o’clock shadow.” Stubble is seen as particularly dangerous. This is also evident in the summary of standards and research from around the world in Lothar Brauer’s Handbuch Atem-

schutz (“Breathing Apparatus Handbook”). Between 1982 and 1990, this 34-page standard ref-erence work, which was updat-ed on several occasions, summa-rized a great deal of information on the subject of beard growth and breathing apparatus. It also explains the physical reasons why short stubble is particularly risky. The stubble is highly resis-

tant to bending and largely remains at a right angle to the skin even when a force is applied, thereby raising the entire seal-ing level of the mask. This creates a gap between the skin and the mask. Longer whiskers, on the other hand, are bent over by the mask’s sealing contour and pressed against the skin. A leak is nonetheless present, although the flow in the spaces between the cylindrical cross sections of hair is generally low-er than in the case of stubble beards. In addition to the length of the hairs, their thickness, the density of the beard growth, and the shape of the hairs also influence the extent of the leak. Despite the current renaissance of the barbershop, most men still shave themselves. This artisanal profession was once part of a man’s daily routine.

There was a time when firefighters of all people were not among the barber’s customers. Until the development of mar-ket-ready breathing apparatus solutions, they were required to grow a full beard, which was said to protect them from haz-ardous substances when tackling fires. Today it is no longer possible to tell which came first: the beard or the desire for protection against smoke particles. The correlation, however, appeared to be clear at the time. In his Chronik der Berliner Feuerwehr (“Chronicle of the Berlin Fire Department”) pub-lished in 1951, Bernhard Peill reported that “the filtering effect of the then popular full beard in smoke-filled rooms was estab-lished early on.”

Such protection was also necessary from the mid-nineteenth century, because Berlin’s fire chief Ludwig Carl Scabell propa-gated the concept of the interior attack. Here, the firefighters had to moisten their beards and tie them over their mouths and noses. At the very most, however, this would have only protect-ed them from larger particles. Smaller particles and especially hazardous smoke gases were still inhaled by the firefighters. An answer to this risk was only found following the blanket intro-duction of self-contained breathing apparatus.

Magnificent:A long beard needs

plenty of time and grooming – like

any fashion

The blade should be held at a 30- degree angle to the skin – that’s the best way to shave whiskers

024_Draeger-117_EN 24 30.01.18 12:47

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THE AVERAGE LENGTH A WHISKER GROWS IN A YEAR – ABOUT

A CENTIMETER A MONTH.

KING CAMP GILLETTE INVENTED THE

DISPOSABLE RAZOR AND BROUGHT IT TO MARKET IN 1903. THE

US ARMY ALONE ORDERED 36 MILLION BLADES FOR THE SOLDIERS FIGHTING

IN THE FIRST WORLD WAR 100 YEARS AGO.

WHISKERS GROW ON THE AVERAGE

MAN’S FACE.

HOURS OF A MAN’S LIFE ARE SPENT SHAVING.

13.97

50%OF ALL MEN IN THE WORLD

HAVE A BEARD.

40TO FAR IN EXCESS OF 200 STROKES OF THE

DISPOSABLE RAZOR ARE NEEDED FOR A WET SHAVE.

30DEGREES IS THE IDEAL ANGLE AT WHICH THE

BLADE SHOULD BE GUIDED ACROSS THE SKIN DURING

A WET SHAVE.

30,000

3,350

METERS WAS THE LENGTH OF THE LONGEST BEARD

RECORDED TO DATE. ITS OWNER HANS NIELSEN

LANGSETH LIVED FROM 1846 TO 1927. A BET WITH

HIS NEIGHBOR WAS MOST LIKELY BEHIND THE

BEARD RECORD.

5.33


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50 Images

26

SCIENCE MEDICINE

The screen of the Dräger PulmoVista 500 displays the tidal volume in the various regions of the lungs in real time


026_Draeger-117_EN 26 30.01.18 12:47

per Second

DRÄGER REVIEW 117 | 1 / 2018 27

MMartin Schwertner knows how to efficiently organize

intensive care medicine. The nurse and respiratory therapist has been working at University Hospital Bochum for 33 years – two-thirds of this time as a care provider on the intensive care unit. Around 10,000 anesthesia procedures are conducted annually in the clinic for anesthesiology, intensive care medicine, and pain therapy. One in seven patients subsequently receives care on the intensive care unit and is often artificially ventilated. Sixty employees care for a maximum of twenty patients simultaneously here. Schwertner appreciates this good care ratio. It gives him time to concentrate on innovative matters as well. The new building, which was completed in 2006, also bears his signature. He made sure the suggestions and needs of his care staff were taken into consideration in the architectural concept. The unit now enjoys plentiful daylight thanks to the floor-to-ceiling windows and the rooms provide sufficient space for maneuvering beds and medi-cal equipment without constantly knocking into things. The same goes for the corridor, in which collisions with the furniture are unlikely even when there is a flurry of activity. “We slotted all of the cupboards into alcoves so we can push the beds along the passage with no obstacles,” says Schwertner. It’s not a mind- blowingly new idea that has improved efficiency here, but rather the attention to detail.

Biofeedback for new applications It is currently the PulmoVista 500 that has roused the interest and curiosity of the unit manager. Dräger’s mobile measuring machine has brought electrical impedance tomography (EIT) to the intensive care unit. He tests it almost

The world of science has known the benefits of ELECTRICAL IMPEDANCE TOMO GRAPHY for a long time. Now doctors and nurses at University Hospital Bochum have been convinced of the advantages of this technology. To their surprise, they discovered that not only artificially ventilated patients benefit from it, but also active convalescents.

Text: Frank Grünberg Photos: Patrick Ohligschläger

daily: “The plan was to use the machine primarily for real-time monitoring of the lung function of ventilated patients. We then realized that other utilization scenarios were possible and that it could even give biofeedback from alert patients. This opened up completely new possibilities to us.” The risk of pneumonia is particularly great following an operation. Surgical procedures often prevent patients from subsequently breathing deeply. If the lungs are insufficiently ventilated, the risk increases of fluid building up in the pleural cavity, the usually narrow gap between the lungs and rib cage. Dr. Günther Oprea, managing consultant of the clinic for anesthesiology, intensive care medicine, and pain therapy, knows how much fluid can accumulate here when the lungs are inflamed: “We recently measured almost one liter in one patient. Around a third of the left lung was affected. This side was no longer sufficiently able to take part in pulmonary gas exchange.”

One such form of monitoring using conventional methods involves a lot of work for the clinic staff and a lot of stress for the patients. The bedridden patients have to be taken for a computer tomography (CT) scan, during

Live wire: Each electrode pair

on the belt sends a small amount of electrical current

into the body. The others calculate the resulting voltage

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“EIT has saved us various CT scans”Dr. Günther Oprea, senior physician at University Hospital Bochum

SCIENCE MEDICINE

Regularly called upon: The mobile measuring machine has been used at University Hospital Bochum since December 2015


which they are exposed to a high level of radiation – all to produce a momentary snapshot. Endoscopic examination of the lungs is also unpleasant for the patient and therefore not particularly suitable for direct monitoring during artificial ventilation. A mobile machine, on the other hand, offers a number of advantages: The PulmoVista 500 works using low electrical currents that the patient is unable to feel. Furthermore, the machine can be taken directly to the patient’s bed in order to measure the lung function in real time with comparatively little effort. “EIT has saved us various CT scans,” stresses Oprea, even though it is no substitute for a CT scan. So why isn’t the procedure used more often in hospitals? “Because it is relatively expensive to buy and thus far it has not been possible to invoice the health insurance companies for the costs.”

Mobile machines have benefitsDräger delivered one of the machines to University Hospital Bochum in December 2015. At a speed of up to 50 images per second, it displays the distribution of air in the lungs and shows how the lung volume changes during ventilation. To make this dynamic process easily

Dr. Günther Opreasees further uses

for the PulmoVista 500 – such as in ambulances

and operating rooms

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29

understandable, the areas of the lung are colored different-ly on the monitor, depending on the regional volume change. The effect of therapeutic measures, which are controlled via the ventilator, can thus be immediately tracked and correct-ed as and when necessary. Is increasing the pressure real-ly benefiting the patient? Is the entire lung being ventilat-ed without over inflating it? These questions can be answered immediately . Electrical impedance tomography is at the tech-nological core of it all. It takes advantage of the fact that the air content influences the bioelectric properties of the pulmo-nary tissue. The more air the tissue contains, the greater the electrical impedance. By taking continuous measurements, the ventilation distribution in the lungs can be determined spatially over time. This makes it possible to ascertain imme-diately what is going on inside the lungs. The world of sci-ence has been aware of the big potential of EIT in the field of intensive care medicine for some time. More than 30 clinical and preclinical trials have highlighted the benefits of the technology for ventilation that is gentler on the lungs. What was missing was everyday experience in the hospital setting. Martin Schwertner and Dr. Günther Oprea have been consistently building up this experience for almost two years.

Intensive tests during day-to-day clinical activity“Working intensively with the technology and sharing thoughts are necessary to test and establish innovations in a tightly scheduled hospital routine. One single person couldn’t manage it on their own,” say Schwertner and Oprea. The same also goes for the pioneering work at the hospital bed. They are both hands-on twice a day on average when they turn the bedridden patients to strap the silicone belt around the rib cage. The belt has 16 electrodes, which provide the required measurement data. Each electrode pair sends a very small amount of electrical current into the patient’s body, while the rest measure the resulting voltage. Since the position of the electrical input rotates around the rib cage during the EIT, the locations where the voltage is measured also change. All of the values can be calculated together after a 360-degree rotation to form a kind of “tomographic image” that provides information on the air distribution in the ventral and dorsal lung regions. On the monitor, the data is displayed in the form of cross-sectional images, graphs, or figures.

The full-screen mode is Schwertner’s favorite for biofeed-back. This shows the ventilation in high resolution and makes it possible for alert convalescents to assess and manage their breathing exercises. Using images, the function shows them

in real time the improvements brought about by their active therapy. “Patients could actually use the machine to get quan-titative biofeedback without any outside help,” says chief phy-sician Oprea, although as yet there are no scientific findings in this regard. It would only be possible to extend the intend-ed use of the machine on this basis. A comparative study with two patient groups could provide the initial impulse here. One group could use the PulmoVista 500 for respiratory thera-py and the other would not have this tool. “I bet,” says Oprea, “that the patients who are immediately able to track the ven-tilation in their lungs would suffer far fewer complications and leave the intensive care unit sooner.” It wouldn’t be the first time that a new technology proved to be more versatile than initially thought. Who would have thought, for example, that the selfie function on smartphone cameras could replace the pocket mirror? Applying makeup with the help of a cell phone is an innovative yet somewhat odd idea at first glance. The PulmoVista 500 could also hold up the mirror for patients in future to help them regain their health more quickly. Dr. Oprea sees additional uses – in the ambulance or operat-ing room, for example, where anesthetized patients are often incorrectly or insufficiently intubated. “This could be immedi-ately identified with the help of EIT.” In Bochum they are now considering testing the PulmoVista 500 in the operating room. The desire for functional improvements is simultaneously growing with the number of usage scenarios. Since the length of the electrode belt is limited, for instance, it makes it diffi-cult and sometimes even impossible to strap it around obese patients. The fact the electrodes don’t work through bandages also restricts the machine’s use in everyday situations. A mile-stone would be achieved if the pulmonary perfusion could be measured on the mobile machine in addition to the ven-tilation. “If I could see the distribution of air and blood at a glance,” says Dr. Oprea, “I would have the entire lungs under control.” Technically, this would be possible.


Martin Schwertner, nurse and unit manager: “It opens up completely

new possibilities to us

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30 DRÄGER REVIEW 117 | 1 / 2018

Cleaning helps to contain the spread of viruses and bacteria. Yet even DISINFECTANTS pose health risks and can boost resistance.

Text: Sascha Karberg

The world was still in order back in the 1980s: There were the “bad” bac-teria and viruses that lurked on grimy door handles and unwashed hands – a constant danger for more or less dan-gerous infections. The “good” power-ful disinfectants made everything clean and hygienic. We couldn’t get enough of them back then. The benchmark was an environment that was as sterile as possible. Researchers now know that too much cleanliness can also be dam-aging. Children who grow up in ster-ile environments, for instance, tend to suffer more from allergies later on than those who scrape up their dropped ice cream from the ground, thereby

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The Trouble with

Germs

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HOSPITAL HYGIENE MEDICINE


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training their immune system with viruses and bacteria. In addition, chem-ical agents in disinfectants can pose health risks. The fact that they don’t just kill bacteria and viruses, but also advance their evolution is also disquiet-ing. Although constant cleaning elimi-nates the germs that have no resistance to biocides, some occasionally remain from among the millions and billions of germs, which then defy the clean-ing agent and subsequently multiply unchallenged.

How disinfectants workOne example is the widely used bacte-ricide triclosan. Initially developed for use in hospitals, it has long since also been used for other purposes, such as keeping textiles free from germs. Envi-ronmental researchers are now record-ing such large quantities of the sub-stance in the River Elbe that it is likely to be damaging the algae that grows there. Triclosan is suspected of impair-ing muscles cells. Furthermore, it is generally dosed in insufficiently high concentrations when used incorrect-ly, increasing the likelihood of resistant germs developing. In 2013, research-ers from the Cary Institute of Ecosys-tem Studies found bacteria in three sewers (near Chicago in the USA) whose flagella – the threadlike struc-tures that enable bacteria to swim – were unharmed by triclosan. Legisla-tors understandably want to counteract this trend so that they can also pro-tect the environment. However, Germa-ny’s VAH (the Association for Applied

be taken into consideration along with the tangible impact on the protec-tion of health when the disinfectants aren’t used.

No further reductionIt is a vicious circle. On the one hand, a patient in a room whose surfaces have been disinfected with germ-kill-ing agents has less risk of infection than a patient in a room where microbi-al traces are left to accumulate across several generations of patients. As such, it makes sense for the associations to call for a greater focus on aspects of health protection. On the other hand, it is sensible to strictly regulate the use of disinfectants in order to prevent the development of resistance and dam-age to health and the environment, including employees who are frequent-ly exposed to the agents. However, this shouldn’t lead to a further reduction in the use of disinfectants, warns the VAH. This would “no longer be tolerated for the sake of public health protection.”

Hygiene) and IHO (the industry associ-ation that oversees hygiene and surface protection for industrial and institu-tional applications) protest that this has not only led to restrictions in the use, but also the rating and approval of new biocides. In a joint declaration, they criticize the fact that the laws “primari-ly emphasize the risks to personnel and the environment without sufficient-ly taking into consideration the impor-tant role played by disinfectants in pro-tecting people’s health.” They argue that certain agents in the disinfectants that can neutralize bacteria and virus-es and are indispensable for hygiene in hospitals, care establishments, and other public institutions. One argu-ment, for instance, draws attention to the fact that the importance of disinfec-tants will only grow in the face of a lack of new antibiotics. Furthermore, bac-teria that are resistant to disinfectants are by no means also resistant to antibi-otics. The statement also points out that the characteristics of antibiotic resis-tance do not usually go hand in hand with an increased resistance to disinfec-tion methods. On the contrary, the asso-ciations argue that there is sometimes even evidence of a higher sensitivity to disinfection measures.

Nonetheless, the use of some prov-en agents is so restricted that they are virtually no longer available for hygiene purposes in the field of human and vet-erinary medicine. Aldehyde-type disin-fectants are one such example. They are effective against a number of bacte-ria and viruses and are considered par-ticularly suitable for using on machines that cannot be sterilized with the aid of heat. However, since they have been classified as carcinogenic if used on a long-term basis, they can hardly still be used in hospitals. “That is why it is necessary not only to look at the ‘abstract’ danger, but also the actu-al resulting risk,” say the associa-tions. At the same time, potential development of resistance and environmental damage should

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32 DRÄGER REVIEW 117 | 1 / 2018

Researchers in the USA have observed that whenever clinical spaces have new occupants, plenty of BACTERIA move in as well.

Text: Sascha Karberg

They follow us wherever we go: bac-teria that live on the skin and in the gut of every person in their billions. That’s a good thing. On the one hand, they aid digestion, train the immune system, and work in harmony with the body. On the other hand, these lodgers are unavoid-ably carried into hospitals when peo-ple have to go there or work there. Even harmless microorganisms can then turn into formidable hospital bugs – and become a deadly risk, particularly to immunodeficient patients.

In Germany alone, around half a million people are infected annually, and at least 30,000 of them die, accord-ing to estimates by the German Society for Hospital Hygiene (DGKH). Research-ers from the Microbiome Center at the University of Chicago have used the opening of a new hospital as an oppor-tunity to observe how it is colonized by bacteria, identify the microbes car-ried in by nurses, doctors, and patients, and establish how the microbial flo-ra changes on door handles and bed frames.

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How Microorganisms Take Over Hospitals

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HOSPITAL HYGIENE MEDICINE


hospital opened. While environmental germs (such as Acinetobacter and Pseu-domonas) dominated at the start, germs typically found on the skin (such as Staphylococcus, Streptococcus, and Cory-nebacterium) began to spread once the humans moved in. After a short while, the researchers examined the patients’ rooms and found the individual microbe composition typical of each patient, pri-marily on the bed frames. “The patient’s microbiome had taken over the hospi-tal room within 24 hours,” says Gilbert.

No standard patternThe researchers discovered that the bac-teria prevalent in the rooms were also present on the skin of new patients – at least initially. The community of micro-organisms typical of the patient only subsequently took over the room. In 92 patients, who had to remain in the hos-pital over a period of several months and were monitored more closely, the researchers discovered bacteria such as Staphylococcus aureus and Staphylo-coccus epidermidis, which can primarily infect immunodeficient patients. Muta-tions of Staphylococcus aureus which are resistant to the antibiotic of last resort methicillin are estimated to be responsible for 30 percent of all hospital infections. Gene variants were actually found in the genetic makeup of some of these bacteria that make them resistant to various antibiotics, thereby increasing the danger of a bacterial infection that can no longer be controlled. The study was unable to tell whether the long hos-pital stay was the cause, or whether such resistance would also be present after a long illness and care at the patient’s home. In any case, Gilbert’s team only rarely discovered traces of the resistant bacteria on the patients’ skin and much IL

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In February 2013, the University of Chi-cago opened the Center for Care and Dis-covery. Two months previously, the team assembled under Jack Gilbert, director of the Microbiome Center at the Univer-sity, was active in the building. Armed with petri dishes, swabs, and other tools of the trade, they identified the bacteria that already existed in the rooms and on the furnishings and equipment before the center even opened. Once the doc-tors, nurses, and patients had moved in, they spent ten months collecting more than 10,000 samples from bed frames, faucets, floors, and air extraction sys-tems. Patients and care staff also had to have swabs taken from their hands, noses, and armpits. In doing so, the researchers not only identified the types of bacteria and their prevalence, but also took 6,523 samples and examined the genetic makeup of the microbes by the gene variants that make them resistant to antibiotics.

The researchers also recorded the temperatures and humidity in the rooms in order to be able to identify potential influences on the transmission and spread of the pathogens. It took three years to evaluate the data. Finally, in May 2017, the findings were published in the journal Science Translational Medicine. As expected, the number and variety of bacteria increased once the

more frequently on hospital surfaces. The genetic makeup analyses revealed that Staphylococcus and Propionibac-terium primarily carry this resistance gene. Gilbert’s study is also unable to tell conclusively how the germs – and in par-ticular the antibiotic-resistant germs – spread in the hospital. “From a statisti-cal perspective, it is more probable that the hospital employees are the source of the bacteria on the patients rather than the other way around,” wrote the researchers. However, no standard trans-mission pattern could be identified.

Temperature promotes the spreadAccording to Gilbert’s study, the type of treatment is not related to the spread of germs: Regardless of whether antibiotics were administered orally or intravenous-ly, or whether patients had undergone chemotherapy or surgery, the microbial mix on their skin remained unchanged. The temperature alone appears to pro-mote the spread of bacteria: patients and hospital staff exchanged more microbes during the warmer months of the year. Even though the study is not yet ful-ly able to trace the path taken by the germs around the hospital, particularly the highly infectious and resistant ones, Gilbert says that it shows the extent to which the microbiological communities on the patients’ skin and the hospital sur-faces are intertwined and how they react to one another.

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ENVIRONMENT AND TECHNOLOGY CRUISE SHIPS

Floating


The North Sea is 40 kilometers away – and yet here, on the banks of the narrow River Ems, two cruise ships more than 300 meters long are built every year. Meyer Werft has secured a 22 percent market share in this niche.

Text: Olaf Krohn Photos: Patrick Ohligschläger

XXL ship garage: The Chinese World Dream – 335 meters long, 18 decks high – left Meyer Werft in Papenburg in mid-September 2017. The ship is designed to accommodate 3,300 passengers and 1,700 crew members. In future, it will sail from China to the Philippines, among other locations

34

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Leisure Parks


The way leads downward, via steep temporary stairs to Deck 1, the ship’s basement, in a manner of speaking, seven meters below sea level – when the ocean-going giant eventually has water under its keel one day. There are pipes, wires, and generators everywhere. At head height there is a tube with several incisions, sup-plying fresh air to the belly of the Norwe-gian Bliss. “Welding work is carried out here using oxy-fuel and shielding gas-es. The rooms are narrow, so we have to make sure that the air is clean,” says Wil-fred de Haan. He is a member of the air monitoring team, which is sent in before-hand whenever employees work in her-metically sealed areas.

De Haan activates his gas detec-tor. “It has four sensors – one each for detecting carbon dioxide, carbon mon-oxide, methane, and oxygen.” Down here on Deck 1, his work is still not done. He quickly forces his way through a small

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36 DRÄGER REVIEW 117 | 1 / 2018

opening and climbs into the darkness – into a future LNG tank. He reappears after a short while: “Nothing of note in the measurements!” De Haan completes a form. His colleagues can now work here without having to worry. The air moni-toring team is called upon to carry out this safety routine between 400 and 600 times a month at one of the world’s most modern shipyards.

Dr. Roland Wittig oversees the occu-pational safety and environmental pro-tection department at Meyer Werft in Papenburg. “The old maxim ‘One ship, one dead’ no longer applies. Our col-leagues should come to work healthy and return home healthy!” Yet the chemist is not just concerned with protecting his colleagues from accidents in the work-place. “We identify all kinds of dangers and stresses, including psychological. This accounts for an ever larger share of the workload.” The shipyard has consid-erably distanced itself from the image of classic shipbuilding, which people deri-sively like to refer to as the 3D industry (dirty, dangerous, and difficult), as Wit-tig is keen to emphasize. “It’s all high-tech here!” No fewer than 500 engi-

neers make sure that a new cruise ship is delivered every six months; if possi-ble larger, grander, and greener than anything the shipping world has seen before. The handover is always a spec-tacle to behold. That’s because the cap-tain, helmsman, and various tugboat crews are faced with a real balancing act when the ocean-going giant cau-tiously makes its way backward towards the North Sea. The ship and river some-how do not appear right for one anoth-er: above the 350-meter-long, 60-meter-high colossus, below a narrow stretch of water flowing from the Teutoburg Forest that seems more like a habitat for inland vessels and fishing boats.

Next step: hydrogen?“May there always be enough water beneath your keel!” No ceremonial ship launch is complete without these winged words and nowhere are they better suit-ed than when a ship is being transferred from Meyer Werft along the River Ems. Twice a year, the barrier in Gandersum dams the river until the shipping chan-nel has reached a depth of 8.5 meters. Every newly built vessel must make the journey through this “birth canal.” Meyer Wirft ticks all the boxes required of a typical hidden champion: It is a pro-vincial family-run business that hardly anyone has heard of, but is a key play-er on the global market in its field. It cannot really hide its activities in the extremely flat region of western Low-er Saxony. At a height of 75 meters, the shipyard’s halls put all the surrounding church towers in the shade. “We have around 3,500 of our own employees in Papenburg, but on average there are between 6,000 and 7,000 people working on the site,” says shipyard spokesman

Günther Kolbe. These are employees from various suppliers, who install engines, elevators, stage equipment, and bumper car tracks on the ship. The shipping companies are increasingly turning their ships into floating leisure parks – complete with grand hotels. And the ships are getting bigger and bigger: Meyer Werft will soon launch the AIDA-nova, the first cruise ship with capaci-ty for more than 5,000 passengers from fall 2018. And Meyer wouldn’t be Meyer if it wasn’t simultaneously planning a world premiere. The AIDAnova will be the first cruise ship to burn neither heavy fuel oil nor marine diesel. Instead, it will be powered solely by liquefied nat-ural gas (LNG). This represents a quan-tum leap in an industry that faces severe criticism for using cheap, but extreme-ly sulfurous, heavy fuel oil (see also Dräger Review 115, pages 50–55). “And the next step,” announces Kolbe, “could then be fuel cell drive systems.”

The VSM (the association represent-ing the political and commercial inter-ests of the German maritime industry) calls the building of cruise ships the ulti-mate discipline in the shipbuilding indus-try. Over the decades, Meyer Werft has continued to perfect its production meth-ods. Since as far back as 1994, Europe’s

Capacity for more than 5,000 passengers

Equipped with a 100 dB multitone alarm: The air monitoring teams at Meyer Werft use the Dräger X-am 7000 multi-gas detector, which is available with up to five sensors. It has a 360-degree warning func-tion that is visible all the way around and a 100 dB(A) multitone alarm as loud as a circular saw

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CRUISE SHIPS ENVIRONMENT AND TECHNOLOGY

37

Measuring ensures safety: High priority is afforded to testing the air quality wherever oxy-fuel and shielding gases are used. This Meyer Werft employee (left) is part of an air monitoring team and is inspecting a gas oil tank. His colleagues can work here if the air is clean. He tests the area with Dräger’s X-am 7000 multi-gas detector (above)


(No) time for a breather:

The work at Meyer Werft actually never

stops – the order books are full until 2023

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ENVIRONMENT AND TECHNOLOGY CRUISE SHIPS

largest laser center has formed the heart of the steel construction center. The pro-duction of passenger cabins, bathrooms, and pipes has been outsourced to subsid-iaries. The process of building the actu-al ship is reminiscent of Lego or Duplo. Smaller steel sections are built, which are subsequently welded together to form blocks, each weighing several hundred metric tons. A cruise ship is made up of several dozen blocks. It is actually a fair-ly obvious process, yet the blocks make for a bizarre spectacle – towering struc-tures with no bow or stern, like steel cake slices that are barely recognizable as a future ship.

Punctual delivery despite the fire“You have to work hard to acquire the expertise needed to build cruise ships cost-effectively,” says Kolbe. Company boss Bernard Meyer took the decision to

specialize in large passenger ships back in 1986. At the time, cruises in Germany were reserved for well-heeled pension-ers who moved in high social circles. It wasn’t until 1992 that the first cruise ship AIDA (now known as AIDAcara) shook up the market. Between 2008 and 2016, the number of German voyagers on the high seas soared from 900,000 to more than two million. While construc-tion work on tankers and container ships has virtually run aground throughout the world, cruise ships have proven to be a lucrative niche still in European hands, despite the attempts of Far Eastern ship-yards to get on board. France, Italy, Ger-many, and Finland are the countries that supply the global market, with the Finn-ish city of Turku home to a second Mey-er location in addition to Papenburg for the construction of ocean-going ships since 2014. The family-run business cur-rently enjoys a 22 percent share of the global market; the order books are full until 2023.

When a shipyard builds such iconic products as dream liners, then it ulti-mately also becomes a desirable destina-tion. The guided tours around the visi-tor center attract 250,000 people every year. From panoramic windows they can look down on the production oper-ation in the large dock hall and admire ship models and original components. The center was still closed when a fire broke out in the dock hall one Saturday morning in the fall of 2016. “The fire spread quickly on Deck 9 of the Norwe-gian Joy,” recalls Erik Feimann. The chief of the company fire department had to raise the full alarm for the whole of Papenburg. “An interior attack wasn’t possible because of the intense heat.” Yet it also proved difficult to fight the fire from the outside due to the great heights involved. “Fortunately, nobody was injured, although there was dam-age to property,” explains Feimann. As

a result of this incident, the company bought its fire department a new aeri-al ladder platform that extends to a res-cue height of 51 meters and is capable of pumping 5,000 liters per minute. The company’s fire department has 90 fire-fighters. “It goes without saying that we also carry out drills with voluntary fire departments,” says Feimann. “How ever, we are dealing with ships here rather than houses.” The ship’s steel gener-ates an incredible amount of heat radi-ation in the event of a fire. Further-more, the firefighters have to get as far into the ship as possible to tackle the blaze. “These interior attacks involve covering very long distances,” says Fei-mann, pointing out the surrounding cir-cumstances. That is also why long-term breathing apparatus and thermal imag-ing cameras from Dräger are used. “The cameras should always be carried when crawling around the ship in zero visi-bility.” Incidentally, the Norwegian Joy, whose cabin area suffered such severe fire damage one year ago, was also delivered on time, just like all the other cruise ships before it. The people from Meyer Werft would like to see somebody else manage that!

Europe’s shipyards dominate the market

Steel cake slice: Cruise ships are not cast, but joined together using several sections that ultimately create the entire structure

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Smoke-free: Meyer Werft is building the world’s first cruise ship to run on LNG for Aida Cruises.www.draeger.com/117-39

Up high: Cruise ships are not houses, but structures of extraordinary dimensions. In summer 2017, Meyer Werft bought a vehicle with an aerial ladder platform that extends to a height of 51 meters to tackle fires effectively on the upper decks in future

A place for everything: Equipment and documents are stored safely in the company’s fire department


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Entre preneurs


Good prospects: Matthias Schmittmann

(left) and Johannes Weber have developed an

innovative gas detector

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HAZARDOUS SUBSTANCES NATURE AND SCIENCE

41

“A university lecturer who specialized in environmental analysis showed us the functional model of a gas chromatograph that can detect hazardous substances,” says Johannes Weber, taking up the thread. Both men, who are in their late twenties, bring one such sample into the meeting room of their company, which, as a spin-off of the Hamburg University of Technol-ogy, is permanently based on the campus. Weber holds up the unit, which is reminis-cent of a laser gun. By contrast, the device that they have made out of it over a devel-opmental period of two years is small and practical: The Dräger X-pid 9500 mobile gas detector is the top-of-the-range model in a small series.

“We can use it to accurately detect all kinds of volatile hydrocarbons and mea-sure even the smallest concentrations,” says Matthias Schmittmann, who complet-ed an MBA after graduating as a chemical engineer. It will prove particularly useful for detecting the presence of the carcino-genic substance benzene, for which the EU workplace limits will be significantly cut even further in 2018 (from 60 ppb to

just 6 ppb). The abbreviation ppb stands for parts per billion. “In Hamburg alone, the basic ambient level of benzene is currently between one and two ppb,” adds Johannes Weber, who as an industrial engineer takes care of commercial matters as well as the software for the X-pid, which is becoming increasingly more important.

Even non-professionals can work itThere was still quite a lot to do, however, before the finished product stood before them. In this regard, the duo proved to be the perfect team. They researched the mar-ket, surveyed users, and explored poten-tial. The idea matured into a business plan, which in turn evolved into a com-pany. It won awards, applied for fund-ing, and convinced critical investors. “We clearly had the right idea,” says Schmitt-man. “Many start-ups,” adds Weber, “con-centrate on service concepts. Now there appears to be a trend back toward business models where the emphasis is on techni-cal innovations.” And the start-up, which now employs 11 people, focused on pre-cisely this area: combining the technical

A

with a Good NoseChemicals can damage the environment and people’s health. Therefore, threshold values are set which can be tested by gas detectors. The Hamburg-based start-up BENTEKK impressed Dräger with its analytical measurement technology – so much so that the technology company from Lübeck acquired a 51 percent majority stake in the business in spring 2017.

Text: Nils Schiffhauer Photos: Patrick Ohligschläger


processes of the gas chromatograph (GC) and the photoionization detector (PID) in one handy device. “We developed the prod-uct in a rather evolutionary manner,” says Schmittmann, looking back. Their profes-sor’s original model was more suited to measuring the presence of hazardous sub-stances on brownfield sites. “Yet this mar-ket is saturated,” says Weber. “Laborato-ries are competing against one another at low prices.” However, measuring hazard-ous substances in industry – in refineries and on drilling platforms – appeared to be a more promising and lucrative market, but the technology had to be very much smaller and capable of being operated by non-professionals. The power consump-tion played just as big a role here as a short measuring time. Even though long measuring times provide a high resolution when identifying various substances, they drastically cut the utility value.

Initial focus on benzeneHere the duo came up with innovative solutions. As a result, the device can continuously measure the sum total of

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NATURE AND SCIENCE HAZARDOUS SUBSTANCES


volatile substances in the ambient air. Johannes Weber removes the cap from a felt-tip pen, whose solvent is barely notice-able as it spreads across the room. The X-pid shows a signal almost instantaneous-ly. “Although we now know that a volatile hydrocarbon is present in the air, as yet we are unable to identify which one. We also cannot tell whether it is carcinogenic.” If a suspicious substance has been found in the first test mode, it can be identified in the second mode along with its concen-tration in ppb or ppm (parts per million). The technique is as clever as it is practi-cal. Its inventors have had the underlying technology patented.

spring 2017, Dräger acquired 51 percent of the shares in the company. The ben-tekk X-PID became the Dräger X-pid 9000 and 9500. The latter measures more tar-get sub stances and can be configured by the user. Both versions were unveiled at the A+A trade fair for occupational health and safety in Düsseldorf in October 2017 and are set to be made available as explo-sion-protected products.

“To do this, we separated the actual measuring device from the unit responsi-ble for displaying, controlling, and evaluat-ing the measurement data,” says Johannes Weber, explaining the concept, which links an explosion-protected sensor unit to an equally explosion-protected Android smart-phone via Bluetooth. “It would have taken us years to develop an explosion-protected communication module by ourselves; not least one that can also transmit the data from our measurement device to any loca-tion via mobile communications.” They consistently see the X-pid as part of the Internet of Things, although it goes with-out saying that the information is always protected when being transmitted.

After three years, the idea became a product that well and truly convinced Dräger, a globally leading company in the field of gas detection technology. “It was a good thing that we had a broad range of knowledge and interests, including chemis-try, hardware, software, and business man-agement.” Their enthusiasm casts doubts on whether all of the prejudices held against Generation Y are really justified.

Up and away: The Dräger X-pid measures volatile hazardous substances in the ambient air and identifies their concentrations in parts per billion

It took just three years to turn the idea into a finished product

“We benefited from the fact that we initial-ly concentrated on the especially critical substance benzene and only then began enhancing our device to identify other sub-stance groups,” explains Schmittmann. This is primarily a software matter. The software itself assigns the measured val-ues (by intensity and time) to the right substances even if the raw data consists of overlapping signals. This didn’t go unno-ticed. Dräger also became aware of the innovators. “They were impressed by the technology,” recalls Johannes Weber, “and since securing an interest in the compa-ny they have assisted us with the impend-ing market launch, above all else.” In

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How the X-pid worksThe device combines two different technologies in order to identify the concentration of certain substances in gases: Gas chromatography (GC) separates different molecules from each other. To do this, the ambient air passes through a column that subjects differently sized molecules to different levels of resistance. As a result, small and volatile substances exit the column first, while the larger and nonvolatile substances come later. Each molecule takes a certain length of time (retention time) to do this. The longer the column, the more precise the separation of molecules – however, the measurement time is also longer. At its optimal length, the column is wrapped up like a coil in the X-pid in order to combine the physically required proportions on the one hand with the small dimensions of the device on the other. The photoionization detector follows on from the gas chromatography. The gas exiting the column is ionized by UV light. The high-energy light ejects electrons from specific molecule groups, creating an electrically conductive gas; a cold plasma. If it hits the detector, a space between two wires becomes conductive and a current flows. Separating the substances in the gas chromatograph and subsequently ionizing and detecting them will create the characteristic model of a sample. Each detected sample is shown as a peak on a time scale. Volatile substances can be found at the start of this scale, while the ever more nonvolatile molecules follow as time progresses. Complex mathemati-cal processes ensure the separation of peaks that are located close together and provide broad protection against interaction of the individual substances (cross-sensitivity).

Various molecules are separated from one another using gas chromatography: They exit the columns at different times.

In the sensor module the air exiting the column is ionized. As a result, certain elements become electrically conductive and are then registered in the actual sensor by the quantity and the time they emerge.

Evaluation: Certain substances then appear on a scale based on the time they emerged (position) and their quantity (strength). Powerful algorithms separate curves that run into one another and assign them to the specific substances – by type and concentration – using databases.

Shock-resistant packaging protects the gas detector and all accessories. Its develop-ment didn’t always go so smoothly, but the men behind it always came up with a new idea

Signal

Time

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The left engine is on fire. “Bird strike!” The control tower radios the mes-sage to the firefighters. A flock has collid-ed with the engine. The plane must make an emergency landing. Four fire trucks race to the scene and approach the Air-bus A320. Two of them aim their roof tur-rets directly at the massive blaze for sever-

T

When an airplane catches fire, the first minutes are the most vital for saving passengers. This is also why firefighters must constantly undertake practical training – as they do in the French town of Châteauroux.

Text: Michael Neubauer Photos: Patrick Ohligschläger

Planesin Flames


FIREFIGHTING FIRE SIMULATION

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al minutes. “I really like that,” says Gilles Vidalie, trainer at the Centre Français de Formation des Pompiers d’Aéroport (C2FPA). He is standing by the window of a control room watching the exercise from a safe distance. “The men have posi-tioned the vehicles well.” Vidalie makes notes and will praise the firefighters afterward. The 48-year-old Frenchman,

who previously worked for the Paris Fire Department and at Poitiers Airport, has been teaching at the training center for the French Airport Fire Department for 11 years. The Airbus is just a mock-up; a rust-colored fire simulator made of weathering steel. “Intervention terminat-ed,” report the firefighters over the radio. The fire is extinguished. Airport firefight-

ers have been practicing on the C2FPA’s 15-hectare site since 2007. Here, near Châteauroux, about a three-hour drive south of Paris, they learn how to deal with dangerous situations. Not far from the A320 is the world’s biggest simulator, that of a Boeing 747. While cargo planes take off and land just a few hundred meters away at a former NATO airport,

Ground mock-up: The steel planes at Châteauroux never take off, because they are designed to burn – time and again


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these simulators never take off. Insteadthey burn – time and again. They are made specifically for this purpose. Both simulators provide a total of 30 different places where fire can break out, includ-ing the fuselage, wings, undercarriage, engines, cockpit, ceiling, cabin, toilets, and cargo hold. A conflagration can also be simulated on the taxiway. The simu-lators are supplied by Dräger, along with the technical rooms and remote-control systems. Dräger technology also supplies the liquid and gasiform propane, com-pressed air, and the cooling water for the simulators. During the exercises, the men have to wear heavy breathing apparatus while making their way into the belly of

the aircraft, cutting open doors, and sav-ing lives – and all the while their vision is impaired by thick smoke. The trainers can play the sounds of people scream-ing and shouting via speakers in order to increase the stress on those taking part in the exercises. “It is important that the training content is as realistic as possi-ble,” says Gilles Vidalie. He also says that the men are ultimately more self-confi-dent, because they would know how to react in a real situation. Above all else, compared to their city-based colleagues, the firefighters at the airport have to intervene considerably more quickly.

Brakes often overheatLuxembourg’s airport fire department is training here this week. The nine men enter the meeting room, remove their heavy equipment, and take a seat on the bench. One of them reports that the last exercise went better than the one before it. He had to cool the overheated brakes

on the simulator using the fire hose and had taken up the incorrect position by the undercarriage. “Rims or bits of tire can fly off with tremendous force due to the incredible heat. As such, you always have to make sure that you attack the fire from a certain angle.” The firefight-ers have already completed the theoreti-cal part of the training course. They took a written exam that morning. Now they have to put what they have learned into practice. Back home, they are unable to carry out exercises on this scale. “It is important to gain the experience and face blazes of this kind,” says one of the Luxembourg firefighters.

The scrapped Boeing 747 was once used by Air France. This aircraft is also used to practice how to ventilate them so that the passengers do not

Many people are scared of flying, but accidents only rarely happen


Everything under control: Gilles Vidalie plans, monitors, and documents the training process

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suffer from smoke inhalation. Near-by is a Boeing 737 with no undercar-riage. Grass has already grown around the nose cone – a simulated crash. The wings have been torn off and some of the seats are strewn about outside the plane. Everything also looks in a very bad state on the inside. Heavy, human body-like dummies lie in the aisles. Here, too, the firefighters practice the rescue and recovery of accident victims. This task often affects them more than the fire extinguishing work.

Serious air accidents with fatalities are relatively rare. In 2017, a new (“sen-sationally low”) figure was recorded for air safety in the field of global aviation. Following analysis by the Hamburg-based JACDEC (Jet Airliner Crash Data Eval-uation Centre), the number of fatali-ties in air accidents fell in the first six months of 2017 to 16; the figure for the

same period last year was 175. Howev-er, such accidents cannot be completely prevented. Passengers generally emerge unscathed thanks to the work of the air-port fire departments – when a plane skids off the runway, for example, and ends up on the grass. The brakes fre-quently overheat when the pilot has to abort the take-off, for instance. It is then the job of the airport fire depart-ment to cool them and prevent any fire from breaking out. “The take-off is a crit-ical phase,” adds Jean-Michel Azémar, president of the training center. The

Fire in the passenger cabin:A firefighter battles his way

through the interior of the fire simulator with heavy equipment

Keeping a safe distance: The trainers can remotely ignite and extinguish the fires on the simulators

Take aim: Several fire trucksare available to the firefighters

on the training course. They must learn to point the water cannon

at the source of the fire on the plane as effectively as possible



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engines provide full thrust so that the plane can take off and quickly gain alti-tude. There can be no glitch during this phase. In the training center Azémar sits by a model of a Boeing 747 and points out the ten exits. “The first seconds are vital when a fire breaks out on board.” They are a matter of life and death for the pas-sengers, who need to be evacuated with-in 90 seconds.

The European Aviation Safety Agency (EASA) requires all airport fire depart-ments in Europe to carry out firefight-ing exercises at regular intervals. The firefighters have a basic level of training as well as specialized advanced training. “The bigger the plane, the more exten-sive the safety regulations,” says Azémar. Many firefighters never experience such an incident in their professional careers, but they must be prepared for the even-tuality. “When the time comes, there can be no mistakes made,” explains Azémar. That is also the reason why practical exercises on simulators are so important.

Only a handful of training centers in the world can provide this kind of train-ing; the C2FPA is one of them. In 2003, 35 French airports and the Union des Aéro-ports Français (UAF) invested 15 million euros in the structure of the C2FPA – fore-most among them the operating compa-

ny Aéroports de Paris (ADP) and Paris-Charles de Gaulle, one of the ten biggest passenger airports in the world. Among the training centers that specialize in fire department training, the C2FPA is the only one in the world to be certified by the International Civil Aviation Orga-nization (ICAO) with its TRAINAIR PLUS program. This means that foreign fire-fighters are awarded a certificate that is recognized in their home country. Train-ing courses have been run here for the past 11 years and more than 1,000 fire-fighters undergo the training every year. The various programs last between two and three weeks. Firefighters from Bel-gium, Luxembourg, Switzerland, and Poland have already attended, as have those from the French overseas depart-ments and territories, among them fire-fighters from the airports in French Poly-nesia.

Fear reigns without trainingFirefighters have to keep a cool head and learn to deal with their fear in the event of a disaster. “If you don’t know what to expect, you are general-ly scared,” explains Azémar. Fatalities, seriously injured people, fire, darkness,

A special kind of fitness trainer: The aim of Jean-Michel Azémar, head of the C2FPA training center, seen here on the training ground in Châteauroux, is to familiarize the firefighters with all kinds of fire and disaster scenarios

Hold fire: The firefighters discuss key matters before and after each exercise – and how they fared

Around 1,000 firefighters from all over the world train here every year


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Danger in the skies:Collisions with birds are feared – in the worst case scenario they can bring a plane down. www.draeger.com/117-49

smoke, and screams can be stressful, as can the situation for a group leader who is on the scene of a plane crash with just six men. He has to analyze the sit-uation within a matter of seconds and then issue the right commands: “It can feel incredibly lonely at this precise moment,” says Azémar. Plans are being considered to provide a virtual simula-tion platform for airplane fires. “Imag-ine a plane crash in which 500 passen-gers are rushing out of the plane down emergency slides.” A real exercise with so many people is unaffordable, but it would be possible with a simulator, sim-ilar to a video game. It goes without say-ing that there would still be practical training on the fire simulators. “The firefighter has to be in contact with the fire; that is vital,” says Azémar.



Environmental protection and blazing infernos The law in France prohibits the use of kerosene in firefighting exercises. Accordingly, the B747 and A320 fire simulators work with liquid propane (outside the simulator) and gasiform propane (inside). Unlike kerosene, propane releases less smoke, carbon monoxide, and carbon dioxide when burning. “The simulators are very eco-friendly,” says Jean-Michel Azémar, C2FPA president. “The fire is very similar to a kerosene fire.” The training center uses around 100 metric tons of propane for the firefighting exercises every year. The fires are managed by computer or remote control from the control room. There are two ways of ending them. The gas can be switched off manually or auto matically: As soon as sufficient water has been sprayed onto the fire, thereby cooling the temperature, the sensors reduce the gas supply. “The aim is to ensure that the firefighters are confronted with a situation that is as realistic as possible,” stresses Jean-Luc Vogler-Finck from Dräger. When it comes to extinguishing water, the C2FPA also opts for an eco-friendly solution. It is purified, fed into a retention reservoir, and reused for future exercises. The firefighters can also use special exercise foam. The residue is then recycled in a treatment plant.

Nicely parked: The fire trucks are housed in this building on the edge of the training ground

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Experienced network:Dräger TGM service engineer

Christopher Joost with an ultra-sound machine at the central

operating room of University Hospital Schleswig-Holstein in Kiel

“We Bear the

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MEDICAL TECHNOLOGY BUSINESS

DRÄGER REVIEW 117 | 1/ 2018 Risk” 51

Service from a one-stop shop, even for heterogeneous machine environments: That is not only the dream of many hospitals, but also the business model of DRÄGER TGM, guaranteeing maximum availability in places like University Hospital Schleswig-Holstein.

Text: Constanze Sanders Photos: Patrick Ohligschläger

Success is about possessing the very skill that is needed at a particular moment in time. An American car designer once described this as the key principle under-lying the division of labor. Christopher Joost is also well aware of this when he arrives at the workshop every morning at half past six. In Building 11 on the grounds of University Hospital Schleswig-Holstein (UKSH), the medical engineer first checks to see which ward immediately needs him. “I check my e-mails every morning to see what has come in overnight.” Togeth-er with his colleagues from Dräger TGM (a Dräger subsidiary concerned with the technical management of machines), he makes sure that not one screw is loose on any of the machines on the Kiel campus of UKSH. “Even a small fault on a single component can stop an MRI scanner or ventilator,” says Joost. “Something like this is given top priority.”

The medical technology service at UKSH has been in the hands of Dräger since 2010. The size and complexity of the hospi-tal – with its 13,000 employees, 85 clinics and institutes, and cutting-edge research

facilities in Lübeck and Kiel – were the main reasons for sharing the responsibili-ty for technical matters with a system part-ner. Dräger TGM takes care of the techni-cal management of machines from a wide range of manufacturers on behalf of UKSH. The contract was extended for an addition-al five years last year. “Our medical and service engineers make sure the machines are used purposefully and coordinate their efficient use within the hospital,” says proj-ect manager Sven Wach, who oversees the TGM budget in Kiel.

98 percent availabilityNine engineers cover the extensive Kiel site alone every day. Each of them is responsi-ble for specific buildings and specializes in certain machines. “We have a fault report-ing module,” says Joost. “ Nurses and caregivers can report any faulty machine by quoting its number online around the clock.” The instinct for knowing what has to be dealt with right away comes from the close contact with the clinical staff. Dräger guarantees 95 percent availabili-ty for the normal equipment and 98 per-cent for the complex technology used at the hospital. “We bear the risk,” says Christopher Eggert, TGM regional man-ager for Schleswig-Holstein and Hamburg. Around 65,000 machine movements are

documented every year. This equates to 180 tasks per day for the 25 employees in the areas of technology, support, and administration in Lübeck and Kiel.

The advantages for the hospital are clear: The in-house technical experts pro-vide a one-stop shop for repairs, replace-ment and loan machines, maintenance, and administration – regardless of the manufacturer. At the same time, it has a central contact for ensuring the trouble-free operation of its products. Dräger TGM is the interface and service provider for both, freeing up the hospital to concen-trate on patient care. UKSH pays a fixed seven-figure sum for this service annual-ly. Downtimes are electronically record-ed and billed with meticulous precision. The extensive documentation supports the legal requirement for doctors and nurses to be accountable and preserve evidence. This includes the time of shut-down and inspection as well as the result of the inspection – there is an entry for every step. The wards can view the status

S

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52 DRÄGER REVIEW 117 | 1 / 2018

Everything in hand: Neatly organized, the workshop accessories ensure maximum availability

Daily team check: Deputy nursing manager Patrick Ehlers (left) and Christopher Joost by a monitor (type: Dräger Infinity M540)

of the repair on the system, including the expected completion time. “We want to be as transparent as possible,” says Egg-ert. TGM engineer Joost covers several kilometers a day traveling between the 25 buildings on the campus in Kiel to pick up faulty machines and drop off repaired ones. Every cable, every sensor, every tube can be replaced. Workshops and spare part warehouses make it possible to carry out the repairs on-site.

First-line service in the medical industryJoost and his colleagues work as part of a team with nurses, caregivers, and doctors to rectify faults and improve applications. “We are always very interested in what is happening with a particular machine,” says chief physician Dr. Dirk Schädler, “particularly since we are duty-bound to report such matters.” If a machine is faulty on the ward, Joost immediate-ly takes it out of service. “Personal con-tact with the users is very important,” says project manager Wach. “This natu-rally improves communication and ulti-mately saves money.” The common aim

is the safety of all patients. Even when they are out and about, the engineers are immediately on hand via their pager and are the first to carry out a fault analysis. The first-line service uses its intuition and technical expertise to ease the acute treat-ment situation and helps to prevent errors among the flurry of activity in the hospital. An incorrect setting or wrongly attached cable is soon rectified. “It’s also about reaction times,” says Wach. “Every man-ufacturer has an interest in ensuring that their machines work as perfectly as possi-ble.” Dräger TGM also wants this, because the external service is provided at the expense of its own budget. “Make-or-buy decisions are therefore among the daily challenges faced by the engineers. They only work on machines for which they are trained and authorized. Everything else is sent to the relevant manufacturer. This gives the hospital planning certainty. Joost often works with Patrick Ehlers. As a dep-uty nursing manager, he is also responsi-ble for the machines. “Since we work non-stop with the various products, one can get damaged every now and then.” Ehlers keeps a constant eye on the equipment and accessories and has a direct line to the service engineer. Anesthetic machines and intensive care ventilators often run around the clock, sometimes for weeks on end. “Nonetheless, the machines fail

extremely rarely,” says chief physician Schädler. And what if they do? “Then we always have bag valve masks on hand. We can immediately separate the patient from the machine and continue to ven-tilate them manually. In the meantime, we search for a replacement machine.” UKSH serves as an experienced network for a complex range of equipment that is efficiently rigged out, organized, and opti-mized by Dräger TGM. Since breakdowns cannot be completely prevented, there is a backup concept for every function – whether ventilation, dialysis, or infusion

One common aim is the safety of all patients

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MEDICAL TECHNOLOGY BUSINESS

Leasing: Dräger TGM has a fully equipped intensive care unit at UKSH – the hospital can make full use of it for a fee. www.draeger.com/117-53

Pure precision: Repairs are expertly carried out with a pas-sion for even the smallest detail, guaranteeing both success and safety

Reducing the pressure: Servicing

a mobile oxygen unit on-site

includes special cases, such as the clean room laboratory secured by half a dozen airlock doors, in which research is con-ducted into nanosensors. It is completely shut down once a year so that all mainte-nance work can be carried out.

At UKSH the inspection routine is also performed in line with the provisions of the German Medical Devices Act and the man-ufacturers’ individual specifications. The comprehensive machine file held by Dräger TGM support contains one inspection plan for each unit, with details of the due dates for visual or functional inspections. “This is something we generally do ourselves,” says Eggert. The same goes for corrective maintenance, if the TGM employee has the appropriate training. Digitalization has long since reached the field of medical technology. Ventilators and ultrasound and radiology imaging machines are software-controlled and give doctors and caregivers detailed and fast evaluation and commu-nication options. The continuous monitor-ing of patients is ensured by linking such machines to the hospital system. “These interfaces are a big challenge,” says Eggert. A monitor sends the vital data in real time to the central control center, where the night shift checks whether the patient is OK. “If the network fails for ten seconds,

intervention is immediately necessary to rectify the interruption.”

Minimizing IT network risksThe IEC 80001 standard therefore recom-mends that a risk assessment is carried out on every interface between a medi-cal product and the network to which it is linked: What happens in the event of a break down? How likely is it to breakdown? How can the risks be contained? Dräger is the only company in Germany to offer training certified by the Chamber of Indus-try and Commerce, leading to a qualifi-cation as a medical IT network risk man-ager (see also: Dräger Review 116, page 15). This is designed to guarantee IT secu-rity in complexly networked hospital sys-tems. UKSH is planning to appoint a cen-tral risk manager to draw up the required risk assessment. “You have to be ready for cyber attacks,” says Eggert.

Dräger TGM GmbH manages around

150 establishments and hospitals in

Germany, including University Hospital

Schleswig-Holstein (UKSH). Every year,

around 15,000 faults are reported

and 10,000 repairs carried out.

UKSH has various clinics, institutes, and

research facilities, providing care for

around 400,000 patients annually.

Approximately 13,000 people

work at the sites in Lübeck and Kiel.

therapy – as well as loan or replacement machines. This is contractually stipu-lated. “We do the entire resource plan-ning for this,” says TGM regional man-ager Eggert. Patient safety is based on a kind of standby redundancy of identical systems for treatment and therapy. Above all else, however, it is based on speed and team spirit. The technical service can be contacted 24/7, while support is available during the day by phone or online. Dur-ing the night and on weekends, emergen-cies are dealt with by Dräger’s “Blue Hot-line” in Lübeck, which is linked to every manufacturer. More than 45,000 active medical machines have to be serviced and inspected at fixed annual or six-monthly intervals during ongoing operations. This

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Born Weighing

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HOSPITAL NEONATOLOGY

A handful of human that appears to fit better in a bird’s nest than an incubator: Preterm babies are unspeakably small and yet endowed with an irrepressible will to live. The NEONATAL WARD in the Polish city of Cracow feels it is their task to give these babies a good start in life.

Text: Nils Schiffhauer Photos: Patrick Ohligschläger

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500 Grams

DRÄGER REVIEW 117 | 1 / 2018 55

AA group of young ladies shines down from the photo on the

wall: “Quintuplets born here in 2008 in the 25th week of preg-nancy,” says Ryszard Lauterbach. “It’s a good thing they are girls,” adds the head of neonatology at Cracow’s Jagiellonen University, a place steeped in tradition. “As preterm babies, girls have a great-er chance of surviving and developing normally later on.” Each weighing between 570 and 800 grams, their physical and mental

Preterm babies are looked after by parents (left), committed

staff, and modern technology (right) at University Hospital Cracow

development has been identical to that of children of the same age who came into the world after a nine-month pregnancy.

The 66-year-old Lauterbach still marvels at the successes achieved in his discipline, which he has not only been able to witness over the course of his career, but also help to shape: “Ten to fifteen years ago, a birth weight of under 2,000 grams was considered crit-ical. Nowadays, extremely preterm babies weighing 500 grams have a real chance of survival.” While the focus used to be on pure sur-vival, today the emphasis is on both the baby’s physical and psycho-social development. “This is critical to determining how a preterm

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56 DRÄGER REVIEW 117 | 1 / 2018

A complex interaction of various muscles

colleague here who familiarized us with the concept of ‘kangaroo-ing’,” he recalls. The method of direct physical contact between the preterm baby and the parents immediately made sense to him and his team. Up until that point, the preterm baby had always been separated from its parents – so as not to disturb the baby and also for reasons of hygiene. Nowadays, the twins’ mother routinely dons a gown, disinfects her hands like a ward nurse of many years, and shares her affection between her two daughters Oliwia and Weronika as best she can. The father is also involved in the kanga-rooing. Relatives such as aunts and grandparents are equally wel-come here. All of this has a positive influence, as Professor Laut-erbach is able to prove through his research: “We monitor the children every month they stay with us.” Over the coming years their development is regularly checked. “Some even remain loy-al to us for much longer and visit us as adults,” says Lauterbach.

Suckling also has to be learnedOnce the preterm baby is out of the woods, it has to learn things that full-term babies can already do – such as independent suckling. “At a rough estimate, I would say a good 7,000 children,” says physio-therapist Agnieszka Kulig, replying to the question of how many chil-dren she has taught how to suckle over the 23 years she has been working here. Doesn’t this sucking reflex work automatically by touching the lips? “Unfortunately not, because many preterm babies do not nec-essarily associate it with something pleas-ant as a result of the way they have been fed via a tube up until that point.” This form of direct feeding is necessary, because pre-term babies have either acquired no suck-ing reflex at all or they grow tired before their hunger is even assuaged due to the fact that this activity is strenuous for them. Here the nutrient solution is fed directly into the

baby will develop in later life,” says Lauterbach. “Particularly in the final weeks of a normal pregnancy, the brain develops the most.” He is also conducting research into optimal nutrition for preterm babies in order to promote this development. It is noticeable how the man with the German-sounding name (“An Austrian heritage!”) continues to be fascinated by his career. He could have also been an engineer or a pianist. “In the end, I combined the skills required for both and opted for a medical degree.”

“We are bursting at the seams here,” says Dr. Joanna Hurkała, who manages one of the three wards. She points to the fully occu-pied incubators: “Milenka 520 g” or “Mateusz 770 g” – preterm babies and their weight. Dr. Hurkala and her colleagues work hard to give these little ones the best future possible. This is surely also the case for Weronika and Oliwia, who are on the “Red Ward” – named after the spot colors. They were born on July 4, 2017, weigh-ing 1,520 and 1,070 grams. “The different birth weights of the twin sisters indicate that the mother had problems supplying the fetuses via the placenta,” explains Dr. Hurkała. She is currently standing by a Dräger IncuWarmer (Type: Babyleo TN500, see also Dräger Review 116, page 64), in which Dominik, who barely weighs 600 grams, will grow over the coming weeks. With a mixture of ten-derness and professionalism, she takes his temperature and records his heartbeat: “That’s all OK.” She likes incubators such as this one: “It has everything that a preterm baby needs. What’s more, it’s easy to operate.” This is essential, because it gives the staff and parents the time, space, and opportunity to attend to the psychological and emotional development of these incredibly small human beings.

A holistic view“Over the decades,” says Professor Lauterbach, “I have witnessed how the view of preterm babies has changed – to a certain extent, they have evolved from being an object for which we wanted to cre-ate good physical conditions into a subject that also has psycho-social needs.” And such needs not only contribute to the baby’s immediate well-being, but also better development overall: “By looking at the vital parameters, for instance, we can see the posi-tive effect of being close to the parents,” adds Lauterbach, describ-ing what he regards as a “holistic perspective” and a “focus on the whole human being.” There is a long tradition of paying attention to such matters in Cracow. “As long ago as 1983 we had a Dutch

HOSPITAL NEONATOLOGY

Being close builds trust. Body contact with the father is also important to preterm babies

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Serving humanity since 1788 University Hospital Cracow was established almost 230 years ago and dedicated to Saint Lazarus. Today, the “Szpital Uniwersytecki w Krakowie” – with its 32 departments and 1,600 beds – is one of Poland’s leading hospitals. Almost 4,000 employees treat around 75,000 patients every year; the number of medical consultations in outpatient clinics exceeds 380,000. More than 300 young doctors prepare for their professional career in this teaching hospital under the guidance of experienced specialists. Seven doctors in the neonatology department have a PhD. Together with their team of nurses, physiotherapists, and a psycho logist, they look after the well-being of preterm babies and their parents. If necessary, they can also call on 14 specialists from different departments within the hospital, including surgery, genetics, nephrology, radiology, and ophthalmology.

57

stomach via a thin tube in the mouth. These are all reasons why Agnieszka Kulig and her colleague, Iwona Opach, have to teach the preterm babies how to suckle later on. “Sucking, swallowing, and breathing involve a complex interaction of various muscles,” says Kulig. Based on the Bobath concept, they stimulate and train the necessary muscle groups until the baby can do it by itself. This is the final stage of development in the hospital; after that the children can go to their parents.

There is a sense of real commitment all around. Yet the staff members often work at the limits of their capacity: The figure for preterm births – put at 12 percent – is growing, par-ticularly in the cities. The cause is thought to be stress and a lack of job security. “Furthermore, a medical intern earns less here than the already low average income in Poland,” says Pro-fessor Ryszard Lauterbach. It isn’t even 1,000 euros, although in bustling Cracow everything is also a good 25 percent more expensive than the national average. The thing that motivates everyone, however, is the knowledge that they are working for people’s lives here, and the success can be immediately seen and sensed. This can be contagious, as Professor Lauterbach notes in his closing words: “My son is also a neonatologist!”

Vision: Professor Ryszard Lauterbach,

head of neonatology, has advocated “kangarooing” since 1983

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The Drug Recognition Experts at the Los Angeles Police Department have to pass a demanding class before they can prove that suspects are impaired by illegal substances. A day on patrol in one of the most notorious areas in the city of four million people.

Text: Steffan Heuer Photos: Patrick Strattner

POLICE BATTLE AGAINST DRUGS

On the Hunt for Drugs in Downtown

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“It’s best to drive around early in the morning. That’s when the junkies are out and about to get their fix,” says Jayson Siller. He peers over the steering wheel of his patrol car at a row of tents erected by the homeless on a sidewalk in the center of Los Angeles. It is just before seven o’clock. Some of their res-idents are already up and about. Direct-ly opposite the little city of tents on 6th Street and Wall Street is the Skid Row

police station, where Siller parks his Ford Crown Victoria, which weighs in at almost two tons.

This part of downtown LA is known as Skid Row for good reason. Anyone who ends up here has generally been on a downward spiral, slowly but sure-ly slipping away from normal life. Sev-eral thousand homeless people, many of them drug addicts, sometimes men-tally ill, live here on the open streets –

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Skid Row – Thousands of homeless people crowd into an area covering a few square kilometers, many of

them drug-dependent. LAPD experts regularly check

suspects and catch them red-handed – like the owner

of this crack pipe


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from depressants, solvents, and soporific drugs to cannabis, methamphetamine, crack, and heroin. Together with Kama-ron Sardar, he heads a small elite unit of Drug Recognition Experts (DREs). The LAPD has around 9,000 officers – who are responsible for more than four million residents on an area covering 1,300 square kilometers – but it only has around 90 such drug specialists. Those who wish to be part of Siller and Sar-dar’s team must first undergo months of training and then get recertified on a regular basis.

It’s not easy to find replacementsAfter a short briefing, Siller divides the “students” into four teams, which will patrol Skid Row today using the radio call signs Queen 51, 53, 55, and 57. “Let’s go and get us some bodies,” says the instructor to the officers as he sends them on their way. It is a diverse group of male and female officers of various eth-nicities who have come together from all parts of the city – from the K-9 unit to the traffic division. They wear the usu-al equipment (weighing several kilos) that an officer in the southern Califor-nian city needs: bulletproof vest, service weapon plus two extra magazines, a Tas-er gun, baton, flashlight, handcuffs, and a bodycam worn on the chest, which they activate when they get out of the patrol car. They also carry a laminat-ed card that lists in table form the most important drugs and their effect on the body. Anyone who wants to be a DRE like Siller must possess something else: the

Millions of people and just 90 drug experts

within eyeshot of the city center’s banks, apartment blocks, and galleries. Some wander around in broad daylight bare-foot and with a vacant look, while others have made themselves at home with bar-becues, electric cables, and guard dogs.

Once a month, Siller assembles a team of 20 to 25 colleagues from the Los Angeles Police Department (LAPD) – as he has on this particular Friday morn-ing – to teach them how to recognize the effects of common drugs on actual liv-ing subjects and prove their presence,

Jayson Siller is a committed drug expert at LAPD and one of the leaders of the specialist course

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BATTLE AGAINST DRUGS POLICE

who drive under the influence of alco-hol or illegal substances. He started by taking an alcohol impaired driver course and then became a DRE. “Legalizing cannabis in California will most cer-tainly only increase the [DUI] problem,” fears the officer – particularly against the backdrop of a second referendum that cleared the way for the possession of even hard drugs, including cocaine and heroin, to be treated as a misdemeanor rather than a felony. Jennifer Bernardi-no is one of his latest recruits for simi-lar reasons. She worked as a nurse for 18 years in the emergency room of a hos-pital, specializing in treating victims of sexual violence, before becoming a death investigator for the coroner’s office and ultimately graduating from the police academy in 2014. The officer with the fastidiously brushed-back black hair says that Skid Row is part of her beat. “Working here shows you the hurt that drugs cause – and you can see the wave of crimes happening on the periphery to

support the habit. The least we can do is to get people with a drug problem off the road before they hurt others,” says Bernardino.

Led away in handcuffsNot long after the briefing she finds her first case. On Industrial Street a spin-dly woman crouches down between two parked cars and has just lit a crack pipe. Bernardino and her DRE fellow train-ee The Duong (Team Queen 51), car-ry out checks on the woman in her late forties. They register her unsteady gait, dilated pupils, and increased pulse rate of 110. Once she has admitted to tak-ing drugs, the officers put her in hand-cuffs and take her to the nearby city jail. This is where the actual part of the DRE course happens. Siller’s students have to complete a 12-stage report consist-ing of several pages: Take the pulse and blood pressure several times at regular intervals, determine the pupil size with millimeter precision under different

right kind of motivation to put in extra work for no extra pay, because the rest of the force depends on them. “If an officer on patrol encounters somebody who seems to be under the influence, they’ll call us,” says the wiry police offi-cer with short salt-and-pepper hair. “The dispatchers receive hundreds of requests every year, and we have to decide what to do when we’re on duty. Unfortunate-ly, we can’t be everywhere.”

He has been a DRE for eight years and has worked as an instructor for sev-en. “It’s not easy to find replacements. We lose about 20 DREs every year because they move on, so we’re constant-ly fighting to keep our headcount.” Why did Siller choose to work voluntary over-time? He doesn’t have to think about it for very long: “Becoming a DRE was a very personal decision for me. Two mem-bers of my family were hurt because of DUI drivers – one of them even got killed.” Since then he has made it his mission to take people out of circulation

Waiting: The LAPD drug experts take suspects to

the city jail, where they must wait for detailed

testing. The officers often find something, but can do nothing about the causes


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POLICE BATTLE AGAINST DRUGS

“This is one of the most difficult classes that the LAPD offers. The material and the long test scare off a lot of people, plus the fact that you have to get recer-tified every other year. You have to real-ly want to be a DRE to help the people in your community. I’m doing this for myself, not because I want recognition or an award,” says Christina Reveles. The traffic officer with the neatly part-ed black hair served in the LAPD for six years before completing the DRE class in 2013. She has been working along-side Siller as an instructor since 2017

and on this particular morning she is sit-ting with Bernardino and going through the results of the test she passed.

No binding threshold value She is really pleased to have the extra support: “There simply aren’t enough of us for a city like LA. When I used to call for a DRE nobody would show up.” A DRE only turns up at accidents with serious injuries or fatalities where drugs appear to have played a part. If necessary, the experts are even flown to the other end of the city in one of the 26 police heli-copters. By implication, this means that many drug users slip through the police department’s net due to a chronic lack of expertise. While it is possible to deter-mine by means of a simple alcohol test whether somebody is over the legal lim-it, there is no legal threshold for drugs. The decision as to whether somebody is under the influence of a substance and is impaired by it generally has to be made by a police officer on the scene, who quickly has to make a judgement

lighting conditions, and conduct tests on the subject’s sense of balance. The extensive questionnaire and examina-tion is designed to document the symp-toms as precisely as possible, because it is the only way in which the document (together with a subsequent toxicology report) will stand up in court. The DRE class lasts two and a half weeks. Those who complete it must make at least 12 drug-related arrests within three months on their patrols around Skid Row, cov-er the seven main drug categories, and correctly diagnose nine of these arrests.

The experts are also flown by helicopter, if necessary


Training live: LAPD officers take the pulse of a suspect. In the course of their training to become drug experts, the officers learn to examine people using an extensive 12-stage program

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Photo gallery:Out and about on Skid Row, the district of the lost, with the LAPD drug experts.www.draeger.com/117-63

and seldom has a mobile drug testing unit (type: Dräger DrugTest 5000). By the time a suspect arrives at the station and can be tested, the effects of many substances have already worn off, even though their presence can still be proved in the body for several days afterwards.

Friendly warning“You need to know what you have in front of you or you may think somebody is under the influence when in fact you’re looking at mental illness or a medical emergency. And what looks like fatigue can be the effects of opioids. Telling the difference takes a lot of experience,” says Jillian Klee. The officer from the North Hollywood division has been a DRE for ten years and is always looking to recruit new colleagues. At the same time, she knows that supporting fellow officers patrolling on Skid Row is extra work that not many police officers want to be sad-dled with. “It’s a tough call when you get a call for a DRE from the dispatcher. Do I stay with my division or drive some-where for a few hours?” says Klee – and a few minutes later she is glued to her radio. In her home division an armed man has barricaded himself in. Of course she would like to do nothing bet-ter than help out her colleagues instead of observing how Bernardino and other students examine suspects.

By midday, two arrested individuals have been interrogated and tested – the most recent a young man in his early twenties who has no shoes on his feet, is caked in dirt, and can barely stay upright in the chair due to nervous convulsions.

Anyone who is not found to be in posses-sion of drugs – like this individual – is released with a friendly warning and a ticket, only to quickly disappear into the Skid Row scene once again. The woman with the crack pipe will spend a night in jail for “possession” before a judge will dismiss her case the next morning.

“She knows the drill. At least she’ll get a bed for a night, a shower, and some-thing to eat,” says DRE instructor Siller, soberly explaining the eternal cycle of this

Documented: It will only stand up later in court if it has been recorded in detail. The drug experts make careful notes on every suspect during their examinations and add handwritten comments from their interviews to the forms

Sobering values:The DrugTest 5000 tests saliva samples for drugs – the system de-tects the presence of up to eight substances with predefined limits. Since 2016 it has also been used in California as an aid in court hearings

deadly serious game of cops and addicts playing out on Skid Row. “To really make a difference, we should have 1,000 of us given the size of the department. And mobile test units would also help. But that’s just my idealistic hope.”

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64 DRÄGER REVIEW 117 | 1 / 2018

they have cultivated this drinking tradi-tion for generations. The apes lived on the plantations, where harvested sugar cane soon began to ferment. Nowadays, they take advantage of the same convenience that has also made it an everyday drug for adults – it is cheap, broadly accepted, and available everywhere. Yet why is eth-yl alcohol so well liked by both humans and animals?

Playing with alcohol is a risky game that increases the chances of having an accident and therefore appears to be an illogical pastime for potential prey. How-ever, the fact that creatures with no ritu-als also drink it merely provides research-ers with further evidence that there is a P

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The fact that animals also indulge in

ALCOHOL initially appears to be a para-dox – after all, those who are intoxicated are easy to hunt. And yet some species cannot resist the ethanol. But why?

Text: Silke Umbach

A Romance

TThe apes came with the ships. When

slave traders regularly came ashore in the Caribbean from Africa 300 years ago, they not only transported people to the sugar cane plantations, green mon-keys were also on board: omnivores up to 60 centimeters tall and quite playful. The slaveholders were driven away; the apes remained, particularly on St. Kitts, almost 900 kilometers north of Venezue-la’s capital Caracas, where the primates developed a passion that would amuse tourists and keep scientists occupied: an appetite for drunkenness. On the beach-es, the monkeys steal drinks, sip cocktails through straws, and feast on alcoholic beverages. Researchers are certain that

with Drawbacks

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ALCOHOL SOCIETY

proclivity for ethanol which runs deep-er than our awareness actually registers. This also plausibly explains why most peo-ple who slip into alcoholism deny it for so long and so consistently – even to them-selves. Although alcohol poisoning is dan-gerous, many brains still do not shun it. When hungry waxwings – 18-centimeter-tall songbirds – migrated from the icy tai-ga to Vienna ten years ago, several doz-en of them perished during the flight. They had got drunk on overripe berries. On later journeys the survivors repeated the process of self-stupefaction, but had stopped flying in the meantime.

A victim of excessThe physician Rainer Thomasius, one of Germany’s leading experts in addic-tion and a professor at University Med-ical Center Hamburg-Eppendorf, sus-pects that rationality is inherent in the discovery of ethanol consumption: “Ani-mals were probably unable to pass up the energy it provided, even though the fruit had long since fermented.” One gram of ethanol provides seven kilocalories, while average carbohydrates provide just four. Backing up this thesis is the fact that eth-anol is the only alcohol that can be toler-ated to a reasonable extent. Methanol and the disinfecting alcohol isopropanol are toxic even in small doses. Among some species, ethanol tolerance has increased even further through regular consump-tion: fruit-eating bats, whose stores often ferment, can safely fly with high levels of alcohol in the blood.

Addiction specialist Thomasius sees the consequences of this trade-off with

nature – energy in exchange for a neu-rological impairment – among his often very young patients on a daily basis. It is the intoxication in particular – general-ly experienced with others – that attracts people. Many are able to drink in moder-ation, but ethanol continues to snare vic-tims: “Our typical patient has had very early experiences of alcohol. Full intoxi-cation over the weekend quickly followed on a regular basis – and this turned into a daily habit.” It is an intensive addiction that cannot be overcome without help, and is mostly associated with a low feel-ing of self-worth. Among young men in particular, alcohol abuse is high on the list of the statistics for causes of death; it is the driving force behind violence and accidents – on the road, at work, and also during leisure time (see also page 6 ff.). Even though this became obvi-ous with the invention of distilled spirits more than 1,000 years ago, the cultural acceptance of alcohol in the entire West-ern world is highest among all the intoxi-cants. What exactly makes it so attractive, even in times of abundance?

The fundamental reason probably lies in the structure of the brain. This is pretty similar in apes, birds, and humans, even though the size and complexity dif-fer. The paradox: alcohol works like neg-ative doping. Furthermore, unlike many drugs and medicines, it doesn’t affect specific receptors or systems. Across the board, cognitive abilities are lost, self-control diminishes, the precision of motor functions degenerates, the capac-ity to react is impaired, and judgement is affected. Yet this appears to be precisely

Waxwings got drunk on the alcohol from the overripe berries

of the rowan tree – many of them subsequently perished. They learned

from it. The songbirds inhabit the taiga, but large flocks can also be

found in Europe. This hasn’t always been a good sign through the ages,

as indicated by its Dutch name Pestvogel (“plague bird”)

Aye-ayes live on the island of Madagas-car in the Indian Ocean. The primates are omnivores and clearly drink anything as well. They have claws on the end of every finger and toe – apart from the big toe, which has a nail on the end. Their teeth are more akin to those of a rodent than an ape. They prefer to eat longhorn beetles, which they hunt by tapping rhythmically on the wood of the tree with their extended third finger. While doing so, their sensitive ears listen to the cavity where the insects live and hook them out like woodpeckers. No, they cannot fly

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SOCIETY ALCOHOL

66 DRÄGER REVIEW 117 | 1 / 2018

Alcohol and legal limits: The production of alcoholic drinks is a billion-dollar business – but abuse can be costly. www.draeger.com/117-66

the attraction. One of the first effects is a loss of inhibitions, involving the dis-appearance of the behavioral bounds that subjec tively represent routine and restricted freedom. So it is probably the semblance of an unexpected frivolity that alcohol gives both humans and animals for a brief period of time. Of all things, however, it is the stupefaction of inhibi-tory brain systems that facilitates drink-ing “beyond thirst.”

Universal abstinence – a utopiaProfessor Alan Wayne Jones, forensic tox-icologist at Linköping University in Swe-den, has not only spent many decades continuously developing and improving methods of proving the presence of alco-hol and drugs, the now emeritus pro-fessor of chemistry has also conducted in-depth studies into the history of sub-stance abuse. “Prohibition in America only fueled illegal distillation and smug-gling from Canada,” says Jones. Even the Scandinavian campaigns preaching absti-nence were unable to convince people – but at least it led to a blood alcohol content

limit of 0.02 percent on Swedish roads, the lowest in Europe. This has mitigated the dangers. “However, we should not for-get the fact that around ten percent of the population, predominantly male, abuse alcohol and can be described as clinical-ly alcoholic. Alcohol kills far more peo-ple than heroin and cocaine put togeth-er, because it is so easy to obtain.” The alcohol-seeking monkeys soon became the subjects of the researchers’ studies. Extensive laboratory tests conducted on them and the long-standing experience of therapists like Professor Thomasius show that the higher the social status of a consumer, whether human or ape, the less endangered they are. Yet it can also affect people who are economically bet-ter off. Alcohol dependency runs through every social class. “The coming together of various risk factors increases the likeli-

hood of dependency,” says Thomasius. He and his colleagues very often deal with a whole host of risk factors – genetic, men-tal, and social.

Many young clients come from unsta-ble families; they have problems trusting in themselves and need constant support to wean themselves off. Both Thomasius and Jones know there will be no radi-cal departure from mankind’s romance with alcohol, which has lasted thousands of years. Our animal relations’ appetite for it is evidence of its archaic intensi-ty. Both experts have spoken out against excessive tolerance. Jones says: “In the USA the blood alcohol content limit for drivers is still 0.08 percent, which is far too high. The American Medical Associa-tion has been calling for it to be lowered for a long time, but whenever it is debat-ed, a campaign is launched by brewers, distillers, and the hospitality industry and the initiative comes to nothing.” Thoma-sius is also critical: “A clear line is drawn in traditional cultures: The French and Italians may drink wine for lunch, but among adults. And they do not tolerate binge drinking among young people. We regularly turn a blind eye when we see young people drinking alcohol.”

This shouldn’t be the case, because the immature human brain is probably no more self-critical during ethanol con-sumption than that of the waxwing or monkey.

Green monkeys are primates, but they greet one another as if they’re part of the in-crowd by rubbing noses

Loss of inhibitions comes first – this seems to be the attraction

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INFORMATION SERVICE

67

Our Con-tributionAn overview of some of the Dräger PRODUCTS featured in this issue can be found here in the order they appear. Each product has a QR code which can be scanned with a smartphone or tablet. The relevant product information will then be displayed. If you have any questions about a product or the magazine, write to us: [email protected]

Zeus IE An anesthesia workstation with various core functions, including gas dosing in a completely closed system.Page 16

Infinity M540 A mobile patient monitor that displays real-time information for various vital parameters. Page 52

FPS 7000 A full-face mask with a wide field of vision, which can be combined with various accessories.Page 23

Babyleo TN500 This IncuWarmer provides constant and optimal thermoregulation for preterm babies in open and closed care. Page 56

X-am 7000 Measures up to five gases simultaneously and continuously – for monitoring the ambient air in industrial applications. Page 36

DrugTest 5000 An analysis system to prove the presence of drugs using saliva. Page 63

PulmoVista 500 An electrical impedance tomography machine that

makes it possible to observe the ventilation of different lung regions.

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INSIGHT DIVING EQUIPMENT

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Dräger’s success story began in 1889 with the Lubeca pressure-reducing valve. Now, 128 years later, the Secor7000 shows just how far this technology has come. The pressure reducer 1 made from chrome-plated brass and a diving regulator 2 reliably supply professional divers with breathing air. This comes from a cylinder fi lled to between 200 and 300 bar of pressure, which is screwed onto the pressure reducer via a DIN handwheel 3 (or an INT yoke adapter). There are three high-pressure and fi ve medium-pressure ports here. A dry

suit or BCD can be connected to the medium-pressure ports 4 via ascrew-in infl ator hose so that the diver can set the desired level of buoyancy underwater. A pressure gauge and low-pressure warning device, among other things, can be connected to the high-pressure ports. 5 The low-pressure warning device gives the diver an acoustic and sensory signal when the cylinder pressure reaches 50 bar. The third high- pressure port is designed to accommodate a dive computer’s transmitter.

The diving regulator is connected to the pressure reducer via its inlet 6 and reduces the medium pressure to a level that permits the diver to breathe naturally – two bar at a depth of ten meters. This air is then supplied to the mouthpiece 7 or a connector for a full-face mask (Type: Dräger Panorama Nova Dive). In this case, a special design prevents turbulence such as resonance which would otherwise cause “shuddering” while breathing. A brief press on the front 8 removes water from the system

by means of an “air purge.” For easy cleaning, the housing can be opened without the need for tools. The sys-tem must be serviced every two years and should last at least ten years if maintained properly. A bubble defl ec-tor 9 directs the exhaled air away from the diving mask to keep the fi eld of vision free. The Secor 7000 complies with the standards of EN 250 and is thus also suitable for diving in cold water (as low as 2°C).

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Breathe freely: The Secor 7000 is not only full of tradition, but also full of innovative details that make working underwater safer and – due to the low breathing resistance – easier

Breathe Naturally Underwater

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violence faced by - dräger

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