Anestesia en Medicina

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Review Article

Anaesthesia and pre-hospital emergency medicineA. Booth,1 A. Steel2 and J. Klein3

1 Specialist Registrar, 2 Consultant in Anaesthesia, Queen Elizabeth Hospital, Kings Lynn, UK3 Consultant in Anaesthesia, Intensive Care Medicine, Royal Derby Hospital, Derby, UK

SummaryMajor trauma is a leading cause of death and disability in the UK, particularly in the young. Pre-hospital emergency

medicine (PHEM) involves provision of immediate medical care to critically ill and injured patients, across all age

ranges, often in environments that may be remote and are not only physically challenging but also limited in terms of

time and resources. PHEM is now a GMC-recognised subspecialty of anaesthesia or emergency medicine and the first

recognised training program in the UK commenced in August 2012. This article discusses subspeciality development in

PHEM, the competency based framework for training in PHEM, and the provision of pre-hospital emergency

anaesthesia.

................................................................................................................................................................

Correspondence to: A. Steel

Email: [email protected]

Accepted: 28 September 2012

A 28-year-old motorcyclist is riding along the A47 in

Norfolk when she is struck by a car pulling out from a

junction. She is trapped beneath the car. She has

sustained severe head, chest and limb injuries. Her

Glasgow Coma Score is 7 and she is hypoxic from an

obstructed airway, a flail chest and a pneumothorax. The

Ambulance Service is called.

A highly trained paramedic working on the Trauma

Desk mobilises the closest Helicopter Emergency Medical

Service (HEMS) team consisting of a senior flight

paramedic and an ST6 Anaesthetic Trainee subspecialty

in pre-hospital emergency medicine (PHEM). They arrive

at the scene 15 min after the incident. They perform a

rapid primary survey, recognise life-threatening injuries

and plan to administer a pre-hospital emergency anaes-

thetic to provide neuroprotection and ventilatory support.

Multi-modality monitoring is applied and the team

use a well-rehearsed pre-induction checklist to ensure

the safest possible conditions for an emergency anaes-

thetic. Ketamine 1 mg. kg)1 and suxamethonium

1.5 mg. kg)1 are given intravenously and the airway is

secured with a tracheal tube. Bilateral open thoracosto-

mies are performed and the limbs fractures are reduced

and tractioned. Anaesthesia is maintained using mor-

phine, midazolam and atracurium. Mechanical ventila-

tion is commenced using a lung-protective strategy.

The incident has occurred 12 min from the nearest

trauma unit. The major trauma centre (MTC) is 50 min

away by road and 25 min by air. The team call the duty

PHEM consultant for advice regarding the destination

hospital. Together they agree that the MTC, with neuro-

surgical facilities, is the most appropriate hospital. The

team embark on a primary transfer by air, maintaining

anaesthesia and ventilatory support. They land at the

MTC and hand over the patients care to an awaiting

trauma team using regionally agreed procedures.

Anaesthesia 2013, 68 (Suppl. 1), 4048 doi:10.1111/anae.12064

40 Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland


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The teams performance and the patients clinical

condition is followed up and reviewed at the regional

PHEM governance meeting. The trainee and her

educational supervisor discuss the case and record an

assessment in the trainees online portfolio. The patient

is discharged from hospital six weeks later with a minorcognitive deficit and a left brachial plexus injury. A year

later she is living and working independently.

Care of the severely injuredThe commonest cause of death of young people in the UK

is external causes such a major trauma or suicide [1]. The

mortality and disabilityof those thatdo survive is improved

by the provision of pre-hospital medical support [28].

The NHS Ambulance Services in the UK have the

statutory responsibility for caring for patients during the

pre-hospital phase and conveying them to hospital.

Whilst paramedic training and advanced training

courses such as Pre-Hospital Trauma Life Support

(PHTLS) go some way to managing the majority of

injured patients, a significant number have such severe

injuries that their immediate needs cannot, at present, be

adequately met without the use of physician-based

interventions. In the UK, a paramedic may manage an

average of just two severely injured patients per year,

limiting opportunities to gain expertise. The technical

skill of endotracheal intubation, for example, is initiallylearnt by performing a small number of in-hospital

intubations [9]. A typical paramedic will subsequently

perform one to two intubations per year [9]. Given the

evidence suggesting that trachel intubation needs to be

performed approximately 80 times before a 95% success

rate is achieved, it is clear that this is a skill in which

most paramedics are unlikely to gain proficiency [10].

For this reason, the Joint Royal Colleges Ambulance

Liaison Committee (JRCALC) report of June 2008 stated

paramedic tracheal intubation cannot be recommended

as a mandatory component of paramedic practice andshould not be continued to be practiced in its current

format [9]. Advanced pre-hospital airway management

requires specialist, typically physician-based, resources.

For decades, doctors have been offering voluntary

support to the ambulance service to care for critically ill

and injured patients. With mounting evidence of the

inadequate care that this group of patients receive

pre-hospital, the last few years have seen national

recognition of the need for the provision of high-quality

medical care integrated into the ambulance response [11].

In 1988, a working party report by the Royal College

of Surgeons highlighted serious deficiencies in the

management of severely injured patients [12]. In 2000, a

joint report from the Royal College of Surgeons ofEngland and the British Orthopaedic Association recom-

mended that standards of care for the severely injured

patient should be nationally coordinated and systemati-

cally audited [13]. It also recommended that standards

and outcome measures be developed, against which

institutions can audit the outcome of treatment. The

standards of care recommended in the report include the

use of advance warning systems by the ambulance service,

the establishment of trauma teams, the involvement of an

appropriately skilled senior doctor from the outset and

criteria for the activation of the trauma team. The overall

purpose of these recommendations was to improve the

care of severely injured patients in terms of reduced

mortality and unnecessary morbidity.

One of the recommendations of the 2000 report was

the establishment of a National Trauma Service trauma

hub and spoke network between hospitals in each

geographic area [14].

In 2007, NCEPOD published a report, Trauma:

Who Cares?, acknowledging that the deficiencies iden-

tified decades before persisted (Box 1) [15]. Recognisingthat the chance of survival and the completeness of

recovery were highly dependent on the care that

followed, it stated that, To be effective all processes,

including Advanced Trauma Life Support (ATLS) and

other components of care of severely injured patients

must be embedded in practice at every stage: the scene of

the accident; alerts to the hospital; the journey from scene

to the emergency department; preparations made there;

expertise accessible on arrival and at all subsequent

stages, including transfer to specialist services [15].

Box 1

The current structure of pre-hospital management is

insufficient to meet the needs of the severely injured

patient. There is a high incidence of failed intuba-

tion and a high incidence of patients arriving at

hospital with a partially or completely obstructed

airway. Change is urgently required to provide a

system that reliably provides a clear airway with

good oxygenation and control of ventilation [15].

Booth et al. | Anaesthesia and pre-hospital emergency medicine Anaesthesia 2013, 68 (Suppl. 1), 4048

Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland 41


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In 2010, in support of better trauma care, the

Department of Health, forming a National Clinical

Advisory Group (NCAG), set out a number of recom-

mendations (Box 2).

Box 2

The Major Trauma NHS Clinical Advisory Group

recommendations [16]:

Enhanced care teams (teams capable of delivering

the full spectrum of medical interventions includ-

ing, for example, emergency anaesthesia) should

be available 24 7 to provide care to the patient

with major trauma

Patients with injuries suggestive of major trauma

should be taken to a major trauma centre. Those

who are within 45 min travelling time from the

centre should be taken there directly, bypassing

other units

Some patients will be further than 45 min travel

from a major trauma centre, or be trapped, or willhave an injury pattern or airway compromise that

means that enhanced care needs to be provided

before they can get to the major trauma centre.

This could be through an enhanced care team or

via a closer designated trauma unit

Patients with major trauma who are taken to a

local major unit should be transferred promptly to

a major trauma centre after initial assessment and

optimisation in the emergency department

Enhanced care teams

Enhanced care teams (ECTs) first gained popularity inthe UK in the 1990s. London HEMS established a

doctor-paramedic model of care that has subsequently

been adopted by much of the UK. Most ECTs are

funded through charitable donations, predominantly

through air ambulance charities. The Emergency Med-

ical Retrieval Service in Scotland is the UKs first 24 7

government funded ECT provider.

Most ECTs are mobilised as part of a regions air

ambulance service. Air ambulances themselves are not

funded through the NHS and instead rely on charitable

donations. Whilst physician-based ECTs have beenshown to reduce morbidity and mortality, air ambu-

lances are extremely costly [1721]. Helicopters have the

advantages of speed over longer distances, thus enabling

the scarce resources of ECTs to cover large areas.

Helicopters can be used to deploy teams to patients

quickly for rapid provision of specialist clinical care. It

will not always be advantageous in terms of time,

practicality or safety to convey the patient by air and the

teams in the UK frequently transport the patients to the

appropriate hospital using land ambulances. Air ambu-

lance availability cannot be guaranteed as limitations in

terms of weather mean that there are times when HEMS

missions are not possible. ECTs need land-based

transport available to maintain a 247 service. Thereare currently very few services in the UK that are able to

undertake HEMS missions outside of daylight hours.

Pre-hospital emergency medicinesub-specialty developmentRecognising that existing pre-hospital medical training

was ad hoc and unregulated, the Faculty of Pre-hospital

Care of the Royal College of Surgeons of Edinburgh set

about establishing a professional route to sub-speciali-

sation [22, 23]. In 2011, the General Medical Council

(GMC) formally recognised PHEM as a sub-specialty of

both Anaesthesia and Emergency Medicine [24]. Also

central to the provision of high quality PHEM is the

development of specialist paramedic practitioners in

PHEM, which is outside of the scope of this article.

It has been estimated that up to 250 whole-time

equivalent (WTE) PHEM consultants across the UK

would provide the service and training required for the

provision of medical support and ECTs. PHEM consul-

tants would spend the majority of time in their base

specialty; therefore 600-700 would be required toprovide the equivalent of 250 WTEs [25]. In 2012, the

first formally admitted PHEM trainees began specialist

training [25].

Pre-hospital emergency medicinetrainingThe specialty of PHEM encompasses the knowledge,

technical skills and non-technical (behavioural) skills

required to provide safe pre-hospital critical care and

safe transfer [26].

Pre-hospital emergency medicine specialty traininginvolves 12 months of full-time equivalent out-of-

programme training, typically to be interwoven with

base specialty training. Trainees must have completed

5 years (> ST4) of parent specialty (anaesthesiaemer-

gency medicine) training before commencing formal

PHEM training. Currently the majority of interested

candidates are emergency medicine trainees. It is

anticipated that there will be approximately 25 training

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posts per year nationally. Whilst opportunities exist for

PHEM training elsewhere, the UK is the first in the world

to recognise the sub-specialty formally and to provide

training focused on providing PHEM consultants.

The Intercollegiate Board for Training in PHEM is

responsible for training and assessment in PHEM onbehalf of the College of Emergency Medicine, the Royal

College of Anaesthetists and the Faculty of Pre-hospital

Care at the the Royal College of Surgeons of Edinburgh

[2527].

The PHEM curriculum divides into 10 themes with

four generic cross-cutting and six specialty-specific

themes (Fig. 1).

Although PHEM as a specialty has only recently

been recognised, a number of services within the UK

have been providing structured training for doctors for

many years (e.g. London HEMS, Magpas, Scotlands

Emergency Medical Retrieval Service). The current

PHEM training model used by a number of services

within the UK involves a period of intense classroom

and simulator-based training followed by a period of

supervision, initially direct supervision provided by a

consultant with extensive experience in PHEM and then

progressing to indirect and remote supervision. The

extensive PHEM curriculum, one of the requirements

for GMC recognition of the sub-specialty, is a means ofensuring that all trainees completing PHEM specialty

training have a known spectrum of competences. Such

competences include clinical (e.g. resuscitative thoracot-

omy) technical (e.g. the ability to use a range of

ventilatory devices) and behavioural (e.g. maintaining

situational awareness). Further examples are given in

Table 1; PHEM trainees will be expected to gain

competences across the breadth of the curriculum before

becoming a PHEM consultant.

Many of the competences are covered by a single

parent specialty, but no one parent specialty includes the

full spectrum of competences required for comprehen-

sive PHEM practice a defining criterion for the

creation of a new sub-specialty. Furthermore, while a

given competence may have been achieved through

parent specialty practice, for example the provision of

emergency anaesthesia, the pre-hospital environment is

so different from that in-hospital that additional training

is required.

Pre-hospital emergency medicine training is typi-

cally delivered in two phases an initial developmentalhighly supervised phase followed by a period of

consolidation training with less direct supervision.

Progression through these phases is supported by the

use of formative and summative assessments. Mirroring

in-hospital practice, successful completion of work-

place-based assessments such as Clinical Evaluation

Exercises (CEX), Case-Based Discussions (CBDs) and

Direct Observation of Procedural Skills (DOPS), is

required. Educational supervision is provided by con-

sultants experienced in PHEM practice.

Training is blended, using a combination of on-linestudy, simulation, multi-agency training days, clinical

case discussions, and direct and indirect supervision by

PHEM educational and clinical supervisors. The

simulation training combines a mixture of low fidel-

itypart-task simulations covering specific skill (exam-

ples include the use of pre-hospital tourniquets, limb

splintage, or pre-hospital surgical airways) and high

fidelity simulations. High fidelity simulation involves full

Working inemergency

medicalsystems

Supportingemergency

preparednessand response

Supportingsafe patient

transfer

Supportingrescue andextrication

Using pre-hospital

equipment

Good

medical

practice

Providing pre-hospital

emergencymedical careClinicalg

ove

rnance

Operat

ionalprac

tice

Teamresourcemanagemen

t

Figure 1 Ten themes of the pre-hospital emergencymedicine competence-based curriculum. Four non-clinical cross-cutting themes are placed centrally, withthe six clinical themes placed peripherally. Each theme isfurther divided into units and elements. Each elementrepresents a discrete item of knowledge or a technical non-technical skill. (Figure reproduced with permissionfrom the Intercollegiate Board for Training in PHEM).




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immersion whole-team, multi-professional training,

often outdoors and in austere environments. These

expose the trainee to the complexity of managing a

critically ill patient in challenging time-pressured situ-

ations, from tasking of a case through to handover. High

fidelity simulation is used to train for common high-risk

events such as road traffic collisions, as well as rarer

events such as mountain, marine, rail, chemical and

confined-space incidents.

Pre-hospital emergency anaesthesiaPre-hospital emergency anaesthesia (PHEA) is one of the

most controversial of interventions provided by PHEM

specialists. Pre-hospital tracheal intubation of severely

injured patients has been shown to be potentially harmful,particularly if delivered without appropriate drugs, mon-

itoring, equipment, training and clinical governance [28

31]. However, a number of well-designed studies have

shown that there can be a functional and survival benefit

associated with PHEA [3, 5, 6, 3238]. Recognising that

many patients should not have this intervention with-

held, the Association of Anaesthetists of Great Britain and

Ireland (AAGBI), in partnership with a number of

national organisations, published guidance on the stan-

dards required for the safe provision of PHEA. In essence,

those standards are the same as those used in hospital(including capnography), recognising the limitations of

the operating environment [39].

Those services that have been routinely providing

PHEA have developed systems to improve the safety of

these high-risk interventions (Table 2). The use of

challenge and response checklists is now routine

practice in many systems and has been shown to reduce

the number of safety critical events [40].

The induction agents used by UK PHEM services

continues to evolve. A decade ago, etomidate was used

almost exclusively for patients for PHEA induction butmore recently many services have commenced using

intravenous or intraosseus ketamine (1.02.0 mg. kg)1

depending on injuries and co-morbidities) [41]. Many

publications and texts state that ketamine worsens

secondary brain injury through a rise in intracranial

pressure. More recent evidence suggests that secondary

brain injury is lessened, not only by the avoidance of

systemic hypotension commonly seen with other induc-

tion agents, but also because ketamine attenuates the

haemodynamic response to intubation and appears to

also have neuroprotective properties, provided thatnormocapnia is achieved with controlled mandatory

ventilation [4245].

Suxamethonium is the most commonly used neu-

romuscular blocking agent (NMBA). The use of rocu-

ronium is increasing, in part reflecting increasing

confidence of services in providing systems for failed-

intubation training and management. Sugammadex

reversal is unlikely to be of benefit as generally patients

Table 1 The six pre-hospital emergency medicine specialty-specific themes with examples of a competency containedwithin them.

Specialty-specific PHEM themes Example of competence

Theme 1 Working in emergency medical systems Demonstrates ability to provide effective on-line clinical support

Theme 2 Providing pre-hospital emergency care Demonstrates ability to undertake resuscitative thoracotomy

Theme 3 Using pre-hospital equipment Demonstrates ability to use devices for controlling haemorrhageTheme 4 Supporting rescue and extrication Demonstrates ability to make a rapid assessment of the clinical needs

of a trapped patient

Theme 5 Supporting safe patient transfer Demonstrates ability to integrate patient diagnosis with the

physiological effects of transport

Theme 6 Supporting emergency preparedness

and response

Demonstrates ability to competently perform the role of a tactical

level medical commander

Table 2 Suggestions for organisational attributes thatmay improve the safety of pre-hospital emergencyanaesthesia (PHEA).

The use of clear standard operating procedures including

equipment governance, indications for PHEA, checklists

for PHEA procedure

Immediately available PHEM consultant advice

Post-incident hot debrief

Regular morbidity and mortality meetings

Regular audit leading to changes in practice

PHEM, pre-hospital emergency medicine.




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who meet the criteria for PHEA are already compro-

mised in terms of ventilation, oxygenation or conscious

levels and most services currently routinely using

rocuronium at induction of anaesthesia do not carry

sugammadex. Maintenance of anaesthesia is commonly

achieved by intravenous morphine and midazolamboluses, although a number of increasingly sophisticated

systems are able to provide infusions, enabling the use of

propofol infusions, or target controlled infusions, for

ongoing sedation during transfer [41].

Conventional direct laryngoscopy is preferred for

Plan A by most PHEM services (Fig. 2). Many carry

videolaryngoscopes for the initial management of a

failed intubation (Plan B), and there is increasing

evidence, albeit simulator or hospital-based, that video-

laryngoscopes would be useful for patients requiring in-

line spinal immobilisation. However, a study of one type

of videolaryngoscope known for high rates of in-hospital

success showed a success rate of only 47% (compared

with 99% using direct laryngoscopy) when used by

experienced practitioners during PHEA [46]. Pre-hos-

pital tracheal intubation success rates by PHEM teams

compare favourably with in-hospital emergency depart-

ment rates [47, 48]. Most systems train teams to provide

a surgical airway in the event of a cant intubate, cant

oxygenate scenario, with the incidence of surgical

airway provision in the order of 1% of patients requiring

pre-hospital advanced airway support [49]. Airway

compromise in association with facial trauma is the

commonest indication for performing a pre-hospital

surgical airway, with laryngeal trauma and burns

injuries as other common indications [50]. Most pre-hospital surgical airways are established using cuffed

tracheal tubes, although needle cricothyroidotomies and

narrow uncuffed tubes have been used with varying

degrees of success [50]. Simple methods of obtaining a

surgical airway in the pre-hospital environment with

high success rates have been described these include

use of a scalpel, forceps (or finger) and a bougie [51].

Pre-hospital trauma care follows ATLS principles.

In addition to early advanced airway management and

cervical spine control, ventilatory support (including the

use of bilateral open thoracostomies rather than chest

drains for mechanically ventilated patients with signif-

icant chest injuries), and circulatory support (including

the use of aggressive haemorrhage control, permissive

hypotension, minimal fluid resuscitation, early blood

and blood component transfusions, and early anti-

fibrinolytic therapy) are fundamental to the provision of

high quality critical care that many patients require in

the pre-hospital phase preceding timely transfer to

definitive care.

Figure 2 Emergency airway algorithm for pre-hospital emergency anaesthesia (PHEA). This was developed by theauthors to follow the Difficult Airway Societys failed intubation, failed ventilation guidelines [52] as far as possible, butrecognising some of the limitations and hazards of the pre-hospital environment. ED, emergency department.




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It is likely that the best outcomes are seen when

PHEA is used as part of a bundle of care incorporating

high quality provision of PHEM by highly trained

personnel. This includes facilitation of extrication,

haemorrhage control, damage control resuscitation,

lung protective ventilatory support, neuroprotectionand correct decision-making in terms of tempo, timely

critical clinical interventions, appropriate transport

platform and appropriate hospital destinations.

Inter-hospital transfersIncreasing numbers of secondary transfers are being

undertaken by ECTs that have traditionally only

undertaken primary (from scene) transfers. The PHEM

curriculum requires practitioners to have competences

for both primary and secondary transfers and ECTs are

developing expertise in this area. The increasingly

sophisticated operations allow for both land- and air-

based transfers.

With the implementation of the trauma networks,

patients who are more than 45 min from a MTC will be

taken to the nearest trauma unit. Many of these will then

require urgent secondary transfer to the MTC. There is

comprehensive guidance on the management of inter-

hospital transfers available [53, 54].

Trauma networksAlthough major trauma is a leading cause of death anddisability, it represents less than 2 per 1000 attendances

in emergency departments in the UK [55]. Several

national reports have revealed the sporadic and unstruc-

tured provision of trauma care in many parts of the UK

and highlighted the poor outcomes in terms of mor-

bidity and mortality [5658].

The National Confidential Enquiry into Patient

Outcome and Death (NCEPOD) report of 2007 found

deficiencies in all areas of trauma care including pre-

hospital services, in terms of both organisation anddelivery of care [15]. It emphasised the need for major

trauma patients to be treated in designated major

trauma centres. As trauma represents such a small

proportion of the workload of UK emergency depart-

ments, MTCs with a high caseload to maintain excel-

lence in trauma are widely spaced. The challenge in

improving services involved not only improvements in

clinical care, but in massive structural reorganisation

with the development of trauma networks. In 2009 the

UKs first National Clinical Director for Trauma Care,

Professor Keith Willett, was appointed to lead this

process.

Regionalisation of trauma services relies on several key

elements: the ambulance service; pre-hospital services;emergency interhospital transfer services; trauma units

(other emergency departments within the network); the

MTC; network coordination; and rehabilitation services.

NHS Choices has produced a detailed map that illustrates

that the nearest MTC may be a significant distance away

andmuchof thechallenge is in early identification of major

trauma and facilitating safe, rapid transfer [59]. Clear

guidance regarding on-scene triage of major trauma

patients and hospital bypass are provided by most

networks.

Development and organisation of trauma networks

requires regionalised coordination. For example, one

innovation being adopted by some regional trauma

networks is the creation of a network coordination

service. This is a dedicated 24 7 telephone-based single

point of contact that coordinates all elements of trauma

care from the pre-hospital phase through to rehabilita-

tion. It provides immediate clinical advice from an

experienced trauma physician as well as a link to bed

bureau services (including critical care and specialist

services beds) and a directory to services related to themanagement of complex injuries. Networks are also used

to follow patient flow and monitor performance of

organisations within it.

Pre-hospital emergency medical carefundingThe majority of ECTs in the UK are mobilised as part of

an air ambulance response and are governed, supported

and funded by air ambulance charities. It is unclear at

the present time how clinical commissioning will affect

future models of service delivery.Despite recommendations from NCEPOD and

similar reports calling for NHS funding of specialist

services, current economic restraints mean that at least

in the medium term charity funding will be central to

PHEM provision in the UK. Organisational collabora-

tion between NHS and non-NHS providers is essential

for developing trauma networks, not only for the

provision of high quality clinical care but also for the




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training and development of PHEM specialists. Such

close collaboration already exists in many parts of the

UK.

The future of pre-hospital emergency

medicinePre-hospital emergency medicine specialists are essential

for providing high quality clinical care, strong medical

leadership, professional training and firm governance of

pre-hospital care and interhospital transfer services [27].

Anaesthetists, already central in themanagement of illand

injured patients,have a great deal to offer thesub-specialty

and are ideally placed to help reduce mortality and to

relieve pain and suffering, both in and out of hospital.

Competing interestsNo external funding or competing interests declared.

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