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Helicopter doctors?
Injury (1992) 23, (4), 249-250
Printed in Great Britain
249
Helicopter doctors? A. M. Dalton, A. Botha, T. Coats, T. Spalding, S. Hodkinson, C. Warren and R. Hodgson The Royal London Hospital, London, UK
All roadside procedures carried out by doctors of the Royal London Hospital Helicopter Emergency Medical Service were recorded. Of 100 injured patients treated consecutively, 68 patients required 73 treatments or procedures that were beyond the current training of the ambulance paramedic in the United Kingdom. Doctors are therefore an essent&l part of HEMS operations and allow earlier live-saving medical intervention in the prehosp#a] phase of care.
Introduction Injury is a major cause of mortality and morbidity, a tragic waste of human resource and remains a largely unrecognized, modem epidemic. There were 4662 deaths from injury in the four Thames regions alone in 1989 (Office of Population Censuses and Surveys). Of these, 578 (12 per cent) were in the IS-24-year-old age group, representing thousands of years of working life lost. The Royal College of Surgeons of England report of November 1988 examined I000 cases of patients who died from trauma and highlighted deficiencies in clinical management. There were 486 (49 per cent) dead on arrival at hospital (Anderson et al., I988), and included those dying at the scene or in transit to hospital. The report dealt mainly with inhospital deficiencies, but inferred that many deaths were due to suboptimal prehospital care. In the United Kingdom, prehospital care is delivered almost exclusively by ambulance personnel. This study examines the specific contribution to prehospital management of doctors, working closely with ambulance paramedics in a helicopter service.
Patients and methods The Royal London Hospital Helicopter Emergency Medical Service (HEMS) has been based on the hospital roof-top helipad since August 1990, before which it operated from Biggin Hill airfield in Kent. It is controlled by the London Ambulance Service (LAS) and carries a medical team consisting of an Advanced Trauma Life Support (ATLS) trained doctor at registrar level, specializing in surgery, anaesthetics, or accident and emergency medicine and a paramedic from the LAS who holds the National Health Service Training Authority (NHSTA) certificate. The HEMS team maintains a permanent state of alert during daylight hours every day of the week, responding immediately to call-outs by the London Ambulance Service to the scene of accidents. The medical team resuscitates, treats and stabilizes the patient before transferring the patient to the most appropriate hospital. A series of 100 injured patients managed consecutively by the HEMS team were documented and all procedures © 1992 Butterworth-Heinemann Ltd 0020-1383/92/040249- 02
analysed to establish which were beyond the current training of the UK NHSTA certified paramedic. The NHSTA certificate is the highest, nationally accepted paramedic qualification and includes training in intubation; and infusion, use of the defibrillator, and the intravenous administration of a limited number of drugs used in the management of cardiac arrest. It does not offer training in the use of anaesthetics or muscle relaxants prior to intubation, or permit the intravenous administration of more than 2 litres of fluid. Neither does it include training in the use of Medical Antishock Trousers (MAST), insertion of chest drains, or pericardiocentesis.
Results The procedures carried out are shown in Figure 1. Of the patients in this study, 16 (I6 per cent) required more than 2 litres of intravenous fluid replacement for the treatment of haemorrhagic shock (range 2000-5000 ml). The need for high-volume infusion was based on the clinical signs of hypovolaemic shock. Of the 23 patients who required intubation, administration of anaesthetic agents (propofol or ketamine) and/or muscle relaxants (suxamethonium, pancuronium or vecuronium) was necessary in 16 (70 per cent). Of these patients, 22 had head or facial injuries and were either unable to maintain an adequate airway, or required ventilatory support to improve oxygenation and/or reduce arterial Pco 2. One was in cardiorespiratory arrest. Of 18 thoracic injuries, 4 (22 per cent) required thoracocentesis. Three were for life-threatening haemopneumothoraces with flail segments. Medical Antishock Trousers (MASTi were used in two patients, both of whom had been trapped in their vehicles for over I h. They both had major lower limb and pelvic injuries and remained severly hypotensive despite intravenous fluid replacement of 4000ml and 500oral, respectively. In both cases, blood pressure was maintained until definitive surgery could be performed in hospital. A single pericardiocentesis was performed on a 3-yearold child with multiple injuries and suspected pericardial tamponade. No blood was drained and the patient finally succumbed to her injuries in hospital. A total of 34 patients (34 per cent) required intravenous opiate analgesia for pain which was not relieved by inhaled oxygen and nitrous oxide (entonox) alone. Intravenous opiate analgesia must be used with caution in the shocked patient, both because of its cardiorespiratory depressant effect and its tendency to remove sympathetic drive with subsequent exacerbation of hypotension. Entonox is the only analgesic agent used by LAS ambulance personnel.
250
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 4 Thoracocentesis 4
~esthetics 16
IV analgesia
Pericardiocentesis
34
I
) 2000 ml
16 MAST suit 2
Figure 1. Roadside procedures performed by HEMS doctors. There were 68 patients who required 73 treatments or procedures unable to be carried out by LAS paramedics. No patient died while in transit to the hospital.
phase impossible. The use of doctors at the scene of the accident ensures recording of essential data, allowing the use of TR1SS methodology in the audit of patients who die before reaching hospital. The use of helicopters permits doctors who are trained in prehospital care to reach the severely injured patient and begin treatment in the shortest possible time. It ensures definitive management in the most appropriate centre with the minimum of delay. Because of their medical education, clinical training and practical expertise, doctors can help to reduce the high mortality resulting from suboptimal roadside care (Pepe and Stewart, 1985), Audit is assured. Having doctors on board helicopters has become the norm in Germany, France, Switzerland, Austria, South Africa, Australia, New Zealand and other countries. Experience to date suggests that the UK should continue to follow their lead.
Acknowledgements The authors would like to thank Mr A. Wilson and Mr R. Earlam for their help.
Discussion The role of the doctor in HEMS operations has been questioned in the United States (Trunkey, 1984), where comprehensive hospital-based emergency medical services are mostly staffed by paramedics or flight nurses with extensive training in advanced life support beyond that of the UK paramedic (McSwain, 1987). One study (Schiller et al., 1988) found no survival advantage of a flight physician when compared with ground ambulances manned by paramedics. This study applied only to communities with sophisticated prehospital care systems and conveniently placed trauma centres. The ambulances were staffed by highly trained paramedics functioning under the direct control of a doctor. This is not the case in the UK. Baxt and Moody (1983, 1987a) state that the presence of a doctor on a HEMS reduced mortality by 52 per cent when compared with paramedic-staffed, land-based systems and by 35 per cent when compared with nurse/paramedic helicopter operations. The improvement was due to life-saving interventions at the roadside rather than speed of transport to hospital and was particularly true when considering headinjured patients alone (Baxt and Moody, 1987b). These findings are consistent with those of this study, in which nearly three-quarters of head-injured patients who needed intubation also needed anaesthesia and/or muscle relaxation and therefore required a doctor's skills. Although many of the procedures performed were not technically difficult, it is the decision to treat which is critical and cannot be replaced by training alone. This decision can be made by a doctor on purely clinical grounds, and is not governed by protocol. Rhee et al. (1986), showed that flight physicians make an essential contribution to patient care in 22 per cent of cases. The doctor exercised critical judgement and/or skill over and above that which would be expected of a US trained paramedic in all these cases. The quality of trauma management is most widely assessed using the TRISS methodology (Holroyd, 1986; Boyd and Tolson, 1987). The system incorporates the trauma score and the injury severity score (Baker et al., 1974). The former requires the recording of the Glasgow Coma Score (GCS) (Champion et al., 1981), but the majority of ambulance personnel in London are not yet trained in its calculation (Personal communication, London Ambulance Service Training School). This makes audit of the prehospital
References Anderson I. D., Woodford M., de Dombal T. et al. (1988) A retrospective' study of 1000 deaths from injury in England and Wales. Br. Med. J. 296, 1305. Baker S. P., O'Neill B., Haddon W. et al. (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14, 187. Baxt W. G. and Moody P. (1983) The impact of a rotorcraft aeromedical emergency care service on trauma mortality. ]AMA 249, 3047. Baxt W. G. and Moody P. (i987a) The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. ]AMA 257, 3246. Baxt W. G. and Moody P. (1987b) The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. ]. Trauma 2 7, 365. Boyd C. R. and Tolson M. (1987) Evaluating trauma care: the TRISS method. J. Trauma 27, 370. Champion H. R., Sacco W. J., Camazzo A. J. et al. (1981) Trauma score. Crit. Care Med. 9, 672. Holroyd B. R. (1986) Medical control quality assurance in prehospital care ]AMA 256, 1027. McSwain N. E. (1987) EMT Training Programs. E M T Journal 1, 40. Office of Population Censuses and Surveys (OPCS) 1989. Pepe P. E. and Stewart R. D. (1986) Role of the Physician in the prehospital setting. Ann. Emerg. Med. 15, 1480. Rhee K. J., Strozeski M., Burney R. E. et al. (1986) Is the flight physician needed for helicopter emergency medical services? Ann. Emerg. Med. 15, 174. Royal College of Surgeons of England (1988) Commission on the Provision of Surgical Services. Report of the working party on the management ,of patients with major injuries. Schiller W. R., Knox R., Zinnecker H. et aL (I988) Effect of helicopter transport of trauma victims on survival in an urban trauma centre. J. Trauma 28, 1127. Trunkey D. D. (1984) Is ALS necessary for prehospital trauma care? J. Trauma 24, 86. Paper accepted 8 August 1991. Requests for reprints should be addressed to: Mr A. M. Dalton, 26 Werter Road, Putney, London SW15 2LJ, UK.
Printed in Great Britain
249
Helicopter doctors? A. M. Dalton, A. Botha, T. Coats, T. Spalding, S. Hodkinson, C. Warren and R. Hodgson The Royal London Hospital, London, UK
All roadside procedures carried out by doctors of the Royal London Hospital Helicopter Emergency Medical Service were recorded. Of 100 injured patients treated consecutively, 68 patients required 73 treatments or procedures that were beyond the current training of the ambulance paramedic in the United Kingdom. Doctors are therefore an essent&l part of HEMS operations and allow earlier live-saving medical intervention in the prehosp#a] phase of care.
Introduction Injury is a major cause of mortality and morbidity, a tragic waste of human resource and remains a largely unrecognized, modem epidemic. There were 4662 deaths from injury in the four Thames regions alone in 1989 (Office of Population Censuses and Surveys). Of these, 578 (12 per cent) were in the IS-24-year-old age group, representing thousands of years of working life lost. The Royal College of Surgeons of England report of November 1988 examined I000 cases of patients who died from trauma and highlighted deficiencies in clinical management. There were 486 (49 per cent) dead on arrival at hospital (Anderson et al., I988), and included those dying at the scene or in transit to hospital. The report dealt mainly with inhospital deficiencies, but inferred that many deaths were due to suboptimal prehospital care. In the United Kingdom, prehospital care is delivered almost exclusively by ambulance personnel. This study examines the specific contribution to prehospital management of doctors, working closely with ambulance paramedics in a helicopter service.
Patients and methods The Royal London Hospital Helicopter Emergency Medical Service (HEMS) has been based on the hospital roof-top helipad since August 1990, before which it operated from Biggin Hill airfield in Kent. It is controlled by the London Ambulance Service (LAS) and carries a medical team consisting of an Advanced Trauma Life Support (ATLS) trained doctor at registrar level, specializing in surgery, anaesthetics, or accident and emergency medicine and a paramedic from the LAS who holds the National Health Service Training Authority (NHSTA) certificate. The HEMS team maintains a permanent state of alert during daylight hours every day of the week, responding immediately to call-outs by the London Ambulance Service to the scene of accidents. The medical team resuscitates, treats and stabilizes the patient before transferring the patient to the most appropriate hospital. A series of 100 injured patients managed consecutively by the HEMS team were documented and all procedures © 1992 Butterworth-Heinemann Ltd 0020-1383/92/040249- 02
analysed to establish which were beyond the current training of the UK NHSTA certified paramedic. The NHSTA certificate is the highest, nationally accepted paramedic qualification and includes training in intubation; and infusion, use of the defibrillator, and the intravenous administration of a limited number of drugs used in the management of cardiac arrest. It does not offer training in the use of anaesthetics or muscle relaxants prior to intubation, or permit the intravenous administration of more than 2 litres of fluid. Neither does it include training in the use of Medical Antishock Trousers (MAST), insertion of chest drains, or pericardiocentesis.
Results The procedures carried out are shown in Figure 1. Of the patients in this study, 16 (I6 per cent) required more than 2 litres of intravenous fluid replacement for the treatment of haemorrhagic shock (range 2000-5000 ml). The need for high-volume infusion was based on the clinical signs of hypovolaemic shock. Of the 23 patients who required intubation, administration of anaesthetic agents (propofol or ketamine) and/or muscle relaxants (suxamethonium, pancuronium or vecuronium) was necessary in 16 (70 per cent). Of these patients, 22 had head or facial injuries and were either unable to maintain an adequate airway, or required ventilatory support to improve oxygenation and/or reduce arterial Pco 2. One was in cardiorespiratory arrest. Of 18 thoracic injuries, 4 (22 per cent) required thoracocentesis. Three were for life-threatening haemopneumothoraces with flail segments. Medical Antishock Trousers (MASTi were used in two patients, both of whom had been trapped in their vehicles for over I h. They both had major lower limb and pelvic injuries and remained severly hypotensive despite intravenous fluid replacement of 4000ml and 500oral, respectively. In both cases, blood pressure was maintained until definitive surgery could be performed in hospital. A single pericardiocentesis was performed on a 3-yearold child with multiple injuries and suspected pericardial tamponade. No blood was drained and the patient finally succumbed to her injuries in hospital. A total of 34 patients (34 per cent) required intravenous opiate analgesia for pain which was not relieved by inhaled oxygen and nitrous oxide (entonox) alone. Intravenous opiate analgesia must be used with caution in the shocked patient, both because of its cardiorespiratory depressant effect and its tendency to remove sympathetic drive with subsequent exacerbation of hypotension. Entonox is the only analgesic agent used by LAS ambulance personnel.
250
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 4 Thoracocentesis 4
~esthetics 16
IV analgesia
Pericardiocentesis
34
I
) 2000 ml
16 MAST suit 2
Figure 1. Roadside procedures performed by HEMS doctors. There were 68 patients who required 73 treatments or procedures unable to be carried out by LAS paramedics. No patient died while in transit to the hospital.
phase impossible. The use of doctors at the scene of the accident ensures recording of essential data, allowing the use of TR1SS methodology in the audit of patients who die before reaching hospital. The use of helicopters permits doctors who are trained in prehospital care to reach the severely injured patient and begin treatment in the shortest possible time. It ensures definitive management in the most appropriate centre with the minimum of delay. Because of their medical education, clinical training and practical expertise, doctors can help to reduce the high mortality resulting from suboptimal roadside care (Pepe and Stewart, 1985), Audit is assured. Having doctors on board helicopters has become the norm in Germany, France, Switzerland, Austria, South Africa, Australia, New Zealand and other countries. Experience to date suggests that the UK should continue to follow their lead.
Acknowledgements The authors would like to thank Mr A. Wilson and Mr R. Earlam for their help.
Discussion The role of the doctor in HEMS operations has been questioned in the United States (Trunkey, 1984), where comprehensive hospital-based emergency medical services are mostly staffed by paramedics or flight nurses with extensive training in advanced life support beyond that of the UK paramedic (McSwain, 1987). One study (Schiller et al., 1988) found no survival advantage of a flight physician when compared with ground ambulances manned by paramedics. This study applied only to communities with sophisticated prehospital care systems and conveniently placed trauma centres. The ambulances were staffed by highly trained paramedics functioning under the direct control of a doctor. This is not the case in the UK. Baxt and Moody (1983, 1987a) state that the presence of a doctor on a HEMS reduced mortality by 52 per cent when compared with paramedic-staffed, land-based systems and by 35 per cent when compared with nurse/paramedic helicopter operations. The improvement was due to life-saving interventions at the roadside rather than speed of transport to hospital and was particularly true when considering headinjured patients alone (Baxt and Moody, 1987b). These findings are consistent with those of this study, in which nearly three-quarters of head-injured patients who needed intubation also needed anaesthesia and/or muscle relaxation and therefore required a doctor's skills. Although many of the procedures performed were not technically difficult, it is the decision to treat which is critical and cannot be replaced by training alone. This decision can be made by a doctor on purely clinical grounds, and is not governed by protocol. Rhee et al. (1986), showed that flight physicians make an essential contribution to patient care in 22 per cent of cases. The doctor exercised critical judgement and/or skill over and above that which would be expected of a US trained paramedic in all these cases. The quality of trauma management is most widely assessed using the TRISS methodology (Holroyd, 1986; Boyd and Tolson, 1987). The system incorporates the trauma score and the injury severity score (Baker et al., 1974). The former requires the recording of the Glasgow Coma Score (GCS) (Champion et al., 1981), but the majority of ambulance personnel in London are not yet trained in its calculation (Personal communication, London Ambulance Service Training School). This makes audit of the prehospital
References Anderson I. D., Woodford M., de Dombal T. et al. (1988) A retrospective' study of 1000 deaths from injury in England and Wales. Br. Med. J. 296, 1305. Baker S. P., O'Neill B., Haddon W. et al. (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14, 187. Baxt W. G. and Moody P. (1983) The impact of a rotorcraft aeromedical emergency care service on trauma mortality. ]AMA 249, 3047. Baxt W. G. and Moody P. (i987a) The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. ]AMA 257, 3246. Baxt W. G. and Moody P. (1987b) The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. ]. Trauma 2 7, 365. Boyd C. R. and Tolson M. (1987) Evaluating trauma care: the TRISS method. J. Trauma 27, 370. Champion H. R., Sacco W. J., Camazzo A. J. et al. (1981) Trauma score. Crit. Care Med. 9, 672. Holroyd B. R. (1986) Medical control quality assurance in prehospital care ]AMA 256, 1027. McSwain N. E. (1987) EMT Training Programs. E M T Journal 1, 40. Office of Population Censuses and Surveys (OPCS) 1989. Pepe P. E. and Stewart R. D. (1986) Role of the Physician in the prehospital setting. Ann. Emerg. Med. 15, 1480. Rhee K. J., Strozeski M., Burney R. E. et al. (1986) Is the flight physician needed for helicopter emergency medical services? Ann. Emerg. Med. 15, 174. Royal College of Surgeons of England (1988) Commission on the Provision of Surgical Services. Report of the working party on the management ,of patients with major injuries. Schiller W. R., Knox R., Zinnecker H. et aL (I988) Effect of helicopter transport of trauma victims on survival in an urban trauma centre. J. Trauma 28, 1127. Trunkey D. D. (1984) Is ALS necessary for prehospital trauma care? J. Trauma 24, 86. Paper accepted 8 August 1991. Requests for reprints should be addressed to: Mr A. M. Dalton, 26 Werter Road, Putney, London SW15 2LJ, UK.