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Helicopter Emergency Medical Services in Buenos Aires: An Operational Overview
Air Medical Journal 37 (2018) 367370
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Helicopter Emergency Medical Services in Buenos Aires: An Operational Overview D1X XFernando Landreau, MDD1,2, 2X X * D3X XOscar ValcarcelD4X X, MD 7 D5X XJuan NoirD6X X, MD 1,6 1,3 balD10X X, MD 1,2 D1X XSergio MartínezD12X X, MD 1,4 D7X XGuadalupe PerníaD8X X, MD D9X XMaría L. Orza 1,2 n ~ ezD18X X, MD 1,4 D13X XAlejandro TobarD14X X, MD D15X XMariana IsolaD16X X, MD 1,3 D17X XMariano Nu 1,5 1,6 nD24X X, MD 1,5 D19X XPablo MartínezD20X X, MD D21X XCristian CuellarD2X X, MD D23X XFederico Villagra D25X XAlberto CrescentiD26X X, MD 7 n Aereo del Emergency Medical Care System, Buenos Aires Escuadro HGA (Hospital General de Agudos) Dalmacio Velez Sarsfield, Buenos Aires 3 HGA (Hospital General de Agudos) Dr. Ramos Mejía, Buenos Aires 4 HGA (Hospital General de Agudos) Dr. Juan A. Fernandez, Buenos Aires 5 n Francisco Santojanni, Buenos Aires HGA (Hospital General de Agudos) Donacio 6 HGA (Hospital General de Agudos) Dr. Cosme Argerich, Buenos Aires 7 n General Emergency Medical Care System, Buenos Aires Direccio 1 2
A B S T R A C T
As part of the emergency medical care system, helicopter emergency medical services (HEMS) have a different crew composition from the traditional team. HEMS consist of a pilot, doctor, and firefighter with rescue skills and training in basic life support on board an air ambulance. This allows the adaptation to different environments and increases the varieties of air procedures normally performed. HEMS began operating relatively recently in Buenos Aires. Yet, in 3 years, its use grew to such an extent that in 2015 it tripled, and by 2016 the number of medical assists was 4 times greater than in 2014. Furthermore, over the 3-year study period, 92% to 95% of assisted victims were traffic accident casualties requiring primary care. The HEMS crew is informed about the availability of resources in the acute care general hospitals and can therefore transfer patients to the most appropriate trauma center in the shortest time. However, 75% to 85% of the time, the choice of destination is strongly influenced by the availability of a helipad and the operational safety that it provides. © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Approximately 1.2 million people worldwide die every year from traffic-related injuries, and the number of injured approaches 50 million.1 More than half of traffic collision fatalities are people 15 to 44 years old.1,2 Epidemiological data suggest a ratio of 1 death per 15 injuries requiring hospitalization, with more than 4-fold minor injuries.1,3 Efforts to reduce death rates and improve outcomes center on reducing time to medical aid and transport to a hospital.4-7 In addition, the management of injuries immediately after the collision is crucial to the victim's chances of survival and quality of later life.4,6,7 The Autonomous City of Buenos Aires (CABA) is located in the central-eastern region of Argentina on the western shore of the Rio de la ~ a 3250, 1107 Capi* Address for correspondence: Fernando Landreau, Avenida Espan tal Federal, Buenos Aires, Argentina E-mail address: [email protected] (F. Landreau). 1067-991X/$36.00 © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amj.2018.07.029
Plata. The last official census (2010) estimated its population at 2,890,151 or 14,391,538 when including its metropolitan area, making the city 1 of the 20 largest in the world.8 CABA's public health system serves 21.9% of the population, primarily through 34 public hospitals. Thirteen of these hospitals provide emergency and trauma care for the entire population of the city, meeting the definition of acute care general hospitals (HGAs).9 The emergency medical care system (SAME) is structured around HGAs, which serve as the bases of operations for ground ambulances, whose number depends on the size of each HGA catchment area. Ground ambulances must be able to respond to a "red code" emergency (lifethreatening) within 8 minutes and are supported by a telecommunications service. Ambulance crews are led by a doctor responsible for initial on-site attention and stabilization as well as in-transit care. Five HGAs are designated trauma centers and are staffed around the
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F. Landreau et al. / Air Medical Journal 37 (2018) 367370
Table 1 Distribution by Type of Event of the Air Ambulance Operations With Transfer of Victims by an Emergency Medical Care System Sanitary Helicopter Between 2014 and 2016 2014 Type of Event 1: road traffic injuries
2: other causes of civil trauma
3: nontraumatic pathology
Traffic: motorbike Traffic: car Traffic: multiple collision Traffic: pedestrian No data Subtotal 1 High fall 3m Collapse/flattening Burned Subtotal 2 Cardiovascular Respiratory Neurologic Gastrointestinal Transplant Subtotal 3
No data Total
2015
2016
%
n
%
n
%
n
35.5 40.3 6.5 0.0 12.9 95.2 0.0 1.6 0.0 1.6 0.0 0.0 0.0 0.0 0.0 0.0 3.2 100.0
22 25 4 0 8 59 0 1 0 1 0 0 0 0 0 0 2 62
40.6 23.0 9.6 3.2 18.2 94.7 1.6 0.0 1.1 2.7 1.1 0.5 0.0 0.0 1.1 2.7 0.0 100.0
76 43 18 6 34 177 3 0 2 5 2 1 0 0 2 5 0 187
24.6 16.0 3.3 0.4 48.0 92.2 0.4 0.0 0.4 0.8 0.4 0.0 0.8 1.2 0.0 2.5 4.5 100.0
60 39 8 1 117 225 1 0 1 2 1 0 2 3 0 6 11 244
clock with a neurosurgeon; however, only 1 trauma center has a helipad, making it the preferred destination for all HEMS transfers. When necessary, landing on a public road is available at the other 4 trauma centers.10 Although urban distances within each HGA catchment area are short by design, these areas tend to be particularly prone to vehicular congestion and transportation delays (especially at certain times of the day). The reduction in transport times by HEMS has well-established and widely documented benefits.5,11,12 HEMS are designed to ensure a highly specialized rescue team, treatment initiation on-site, and minimization of delays in transporting victims to trauma centers. Also, HEMS crews receive regular updates on resource availability at all trauma centers to optimize response times, particularly in the event of a multiple-victim accident. Herein, we describe the utilization data of the CABA HEMS embedded in a network of public trauma centers and staffed with a unique crew configuration.
Materials and Methods The SAME HEMS started in CABA in December 2010 under contract, with a private provider (Flight Express SA, Modena Group, Buenos Aires, Argentina) furnishing aircraft (Bolkow-105 helicopters), pilots, and operating technicians, whereas the SAME provides physician staffing. Contract stipulations provide for the availability of 2 helicopters, 1 on active duty during daylight hours and the second as a backup. Meteorological conditions may limit aircraft operational
capacity, and the pilot has decision-making authority on flight conditions. The Bo-105 is a very small twin-engine, multipurpose, light utility helicopter, making it particularly suitable for operating in confined spaces such as urban areas. Unlike usual crew configurations in other countries,13,14 the SAME HEMS 3-member crews include a helicopter pilot and a physician with board certification in emergency medicine and additional qualifications in air evacuation by the National Institute of Air-Space Medicine. The third crew member is a firefighter with prehospital trauma life support certification and basic pilot training; if the pilot is disabled for any reason, he or she can make an emergency landing.15,16 The firefighter (designated herein as an operational technician) is a multitasking technician who usually works as a member of the medical crew but in emergency situations can assume a role as a member of the air crew. We reviewed daily operation logbooks for the SAME HEMS between January 1, 2014, and December 31, 2016, and summarized the distribution by type of event, diagnostic codes, basic victim demographics, and selection of the receiving trauma center.
Results The Argentine Civil Aviation Regulations x91 section L Application Standards for Sanitary Air Operations classifies medical air transport activities into 3 types, namely sanitary evacuation (ES), health air transportation service (STAS), and air transport of organs. ES refers to
Table 2 Distribution of Victims by Diagnostic Code of the Emergency Medical Care System 2014 Diagnostic Code 1 4 5 8 9 10 11 12 15 19 Total
Polytraumatism Mild traumatism Burned Hemorrhage Intoxications Cardiovascular Respiratory Digestive Neurologic Death
2015
2016
%
n
%
n
%
n
51.6 48.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0
32 30 0 0 0 0 0 0 0 0 62
64.5 31.2 1.1 0.0 0.5 1.6 0.5 0.5 0.0 0.0 100.0
120 58 2 0 1 3 1 1 0 0 186
47.8 46.6 0.8 0.4 0.0 0.4 0.0 1.2 1.2 1.6 100.0
119 116 2 1 0 1 0 3 3 4 249
F. Landreau et al. / Air Medical Journal 37 (2018) 367370
369
Table 3 Distribution by Sex and Age 2014 Sex
2015
Male
Female
2016
Male
Female
Male
Female
Age (y)
%
n
%
n
%
n
%
n
%
n
%
n
0-15 16-25 26-35 36-45 46-55 56-65 >66 No data Total
0.0 14.5 29.0 22.6 3.2 3.2 3.2 0.0 75.8
0 9 18 14 2 2 2 0 47
0.0 4.8 3.2 1.6 1.6 3.2 1.6 1.6 17.7
0 3 2 1 1 2 1 1 11
2.1 17.6 22.5 20.3 6.4 5.9 1.6 0.0 76.5
4 33 42 38 12 11 3 0 143
0.5 4.3 5.9 6.4 1.6 1.6 2.7 0.0 23.0
1 8 11 12 3 3 5 0 43
0.0 16.8 29.9 16.0 5.7 3.7 3.3 0.8 76.2
0 41 73 39 14 9 8 2 186
0.8 4.5 5.3 4.1 3.3 1.2 1.2 0.0 20.5
2 11 13 10 8 3 3 0 50
the transfer of a victim or a patient from the place of the incident to a health care center (primary transfer), whereas STAS refers to transfers between 2 medical centers (secondary transfer). The number of ES events increased over the 3 years of the study from 62 in 2014 to 187 in 2015 and 244 in 2016. Until recently, HEMS in Argentina was limited to STAS operations aimed at improving access from rural or mountain areas. The introduction of ES in the CABA area resulted from an expansion of the existing first response system. Emergency calls to the SAME operations center (by calling 107) are handled by operators who dispatch helicopters based on preestablished protocols. A medical coordinator at the air base in communication with the helicopter crew designates the receiving hospital and coordinates patient reception. Dispatch criteria of the SAME HEMS include accidents on urban highways with traffic congestion that makes it impossible for ground ambulances to reach the scene, events with multiple victims, incidents with trapped victims, or the transfer of organs for transplantation. Based on the type of incident, transfers are further classified as victims of vehicle trauma, nonvehicle trauma, and all others (Table 1). Victims of traffic-related trauma comprised over 90% of the total health helicopter transfers each year in the study period. There was no information on record for 2016 about the types of vehicles involved in 48% of traffic-related incidents, whereas for 2014 and 2015, 35.5% and 40.6%, respectively, were motorcyclists and 40.3% and 23.0%, respectively, were victims of car accidents with no distinction between the drivers and passengers. The largest number of victims transferred during the study period received a diagnostic of “polytraumatism,” whereas the second most
frequent diagnostic transfer code was “mild traumatism” (Table 2); these 2 diagnoses combined accounted for more than 90% of the HEMS transfer victims in the 3 years under study. Table 3 provides the distribution of the transported victims by age and sex. The overwhelming majority of the victims transferred by HEMS were taken to the trauma center at HGA Santojanni Hospital, the only center with a heliport on site. Most of the exceptions were burn victims or members of the police force who were generally transported to specialized centers (Table 4). Discussion Most of SAME HEMS operate on urban highways and involve victims of traffic-related trauma. When engaged, the HEMS crew is often the first responder to the incident. In these cases, the operative technician (firefighter) is responsible for environment safety and jointly with the doctor for victim extraction and placement on a long spinal board with a cervical collar and lateral immobilizers, which is locked to a fixation system on the floor of the aircraft. The doctor sits behind the passenger compartment, but because of lack of freedom of movement because of the position and reduced space of the cabin, advanced life support procedures such as endotracheal intubation, chest compressions, or thoracic drainage must be performed before boarding. Likewise, cardiac defibrillation cannot be performed in flight. Because flight times within CABA range from 5 to 15 minutes, the crew's physician must assess the patient's condition before takeoff. However, as shown in Table 2, a large proportion of victims transported by air sustained only mild traumatic injuries. This is because during peak hours, traffic congestion makes it impossible for ground ambulances to reach
Table 4 Distribution of Trauma Victims Transferred by an Emergency Medical Care System Medical Helicopter by the Receiving Medical Center 2014 Receiving Medical Center n Francisco Santojanni (GCABA) HGA Donacio HGA Dr. Cosme Argerich (GCABA) HGA Dr. Ignacio Pirovano (GCABA) HGA Dr. Juan A. Fernandez (GCABA) A. Penna (GCABA) HGA Jose Hospital de Quemados (GCABA) ~ os Dr. Ricardo Gutierrez (GCABA) Hospital de Nin Hospital de Pediatría SAMIC Prof. Dr. Juan Pedro Garrahan (MSN) dico Churruca Visca (PFA) Complejo Me HZGA Dr Narciso Lopez Lanus (GPBA) stor Kirchner (MSN) Hospital El Cruce SAMIC Dr Ne n Lucha contra las Enfermedades Neurolo gicas de la Infancia) FLENI (Fundacio Sin datos Total
2015
2016
%
n
%
n
%
n
75.8 8.1 6.5 4.8 0.0 0.0 0.0 0.0 3.0 0.0 0.0 0.0 1.6 100.0
47 5 4 3 0 0 0 0 2 0 0 0 1 62
83 8 2 0 0 0 1 1 4 0 1 1 0 100
155 15 4 0 0 0 1 1 7 0 2 1 0 187
84 10 0 0 1 0 0 2 3 0 0 0 0 100
206 24 1 0 2 1 0 1 8 1 0 0 0 244
GCABA = Government of the Autonomous City of Buenos Aires; GPBA = Government of the Province of Buenos Aires; HGA = General Hospital of Treble; HZGA = Zonal General Hospital of Treble; MSN = Ministry of Health of the Nation; PFA = Federal Police Argentina; SAMIC = Comprehensive Medical Care Service for the Community.
370
F. Landreau et al. / Air Medical Journal 37 (2018) 367370
the scene within the stipulated 8-minute time frame.17 In such cases, urgency is determined by the assessment of the severity of the victim's injuries.16,18 The age and sex distribution of the victims transferred by HEMS in CABA during the study period (Table 3) matches the published data for fatalities of traffic-related trauma victims.1,2 The choice of the HEMS referral hospital was heavily biased on the availability of a heliport at a single trauma center in CABA. This can be explained by the operational safety of the crew and patients. Landing on city streets requires coordination with a ground ambulance from the hospital and traffic police officers on the ground to ensure public safety.16 Reasons identified on the log for deviating from this preference included the lack of trauma beds at HGA Santojanni Hospital and the presence of burns (requiring specialized care) or uniformed police victims (transferred to the police hospital). Our data cover the daylight operations conducted by HEMS within the CABA catchment area. Summary In summary, this article describes the performance of HEMS operating exclusively within a congested urban setting, the basic characteristics of the victims evacuated by helicopter, and the medical crew's choice of referral target. Unfortunately, we did not have access to the clinical outcome data of the transported victims, which would have provided useful information. Acknowledgment n Ladaga for help editThe authors thank Dana Martinez and Bele ing the text and Dr. Gabriel A. de Erausquin for his advice, helpful discussions, and revision of the manuscript. Supplementary materials Supplementary data related to this article can be found at https:// doi.org/10.1016/j.amj.2018.07.029. References n de 1. World Health Organization and World Bank. Informe Mundial Sobre Prevencio nsito: Resumen. Geneva, Switzerland: Organlos Traumatismos Causados por el Tra n Mundial de la Salud; 2004. izacio
2. de Vigilancia B. Enfermedades no transmisibles y factores de riesgo. Boletín Epidegico. 2011. 6-1727-31. miolo ~ os potenciales de vida perdidos (APVP): una medida 3. Dranger E, Remington P. An que resume la mortalidad prematura para evaluar la salud de las comunidades. Wisconsin Public Health Policy Institute Brief. 2004;5:7. 4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support, ATLS. 9th ed., 2016 The Journal of Trauma and Acute Care Surgery. 74 (5):13636, May 2013. https://doi.org/10.1097/TA.0b013e31828b82f5. 5. Abbasi H, Bolandparvaz S, Yadollahi M, Anvar M, Farahgol Z. Time distribution of injury-related in-hospital mortality in a trauma referral center in South of Iran (2010-2015). Medicine (Baltimore). 2017;96:e6871. 6. Alarhayem AQ, Myers JG, Dent D, et al. Time is the enemy: mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”. Am J Surg. 2016;212:1101–1105. 7. Neira J, Tisminetsky G. Atencion Inicial de Pacientes Traumatizados. Buenos Aires, Argentina: Fundacion Pedro Luis Rivero; 2010. n, 8. Edwin AM. Instituto Nacional de Estadística y Censos. Censo Nacional de Poblacio Hogares y Viviendas 2010. Serie B. Buenos Aires, Argentina: Instituto Nacional de Estadística y Censos; 2012. n porcentual de la poblacio n 9. Estadisticas y Censos, Buenos Aires Ciudad. Distribucio dica segu n comuna. Ciudad de Buenos Aires. An ~ os 2006/ por tipo de cobertura me 2016, 2016. 10. http://www.buenosaires.gob.ar/noticias/sistema-de-atencion-medica-de-emergencia. Accessed oficial website of the government of the Autonomous City of Buenos Aires. 11. Brown JB, Gestring ML, Guyette FX, et al. Helicopter transport improves survival following injury in the absence of a time-saving advantage. Surgery. 2016;159:947–959. 12. Dharap SB, Kamath S, Kumar V. Does prehospital time affect survival of major trauma patients where there is no prehospital care? J Postgrad Med. 2017;63:169– 175. 13. Cardoso RG, Francischini CF, Ribera JM, Vanzetto R, Fraga GP. Helicopter emergency medical rescue for the traumatized: experience in the metropolitan region of Campinas, Brazil. Rev Col Bras Cir. 2014;41:236–244. 14. Abe T, Takahashi O, Saitoh D, Tokuda Y, Daly MJ, et al. Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan. 2010. Critical Care. 2014 Jul 9;18 (4):R146. https://doi.org/10.1186/cc13981. 15. Wilson S, Gangathimmaiah V. Does prehospital management by doctors affect outcome in major trauma? A systematic review. J Trauma Acute Care Surg. 2017;83:965–974. 16. Zalstein S, Cameron PA. Helicopter emergency medical services: their role in integrated trauma care. Aust N Z J Surg. 1997;67:593–598. 17. Weerheijm DV, Wieringa MH, Biert J, Hoogerwerf N. Optimizing transport time from accident to hospital: when to drive and when to fly? ISRN Emerg Med. 2012;2012:1–5. 18. Wilson A, Cross F. Helicopters. J R Soc Med. 1992;85:1.
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Original Research
Helicopter Emergency Medical Services in Buenos Aires: An Operational Overview D1X XFernando Landreau, MDD1,2, 2X X * D3X XOscar ValcarcelD4X X, MD 7 D5X XJuan NoirD6X X, MD 1,6 1,3 balD10X X, MD 1,2 D1X XSergio MartínezD12X X, MD 1,4 D7X XGuadalupe PerníaD8X X, MD D9X XMaría L. Orza 1,2 n ~ ezD18X X, MD 1,4 D13X XAlejandro TobarD14X X, MD D15X XMariana IsolaD16X X, MD 1,3 D17X XMariano Nu 1,5 1,6 nD24X X, MD 1,5 D19X XPablo MartínezD20X X, MD D21X XCristian CuellarD2X X, MD D23X XFederico Villagra D25X XAlberto CrescentiD26X X, MD 7 n Aereo del Emergency Medical Care System, Buenos Aires Escuadro HGA (Hospital General de Agudos) Dalmacio Velez Sarsfield, Buenos Aires 3 HGA (Hospital General de Agudos) Dr. Ramos Mejía, Buenos Aires 4 HGA (Hospital General de Agudos) Dr. Juan A. Fernandez, Buenos Aires 5 n Francisco Santojanni, Buenos Aires HGA (Hospital General de Agudos) Donacio 6 HGA (Hospital General de Agudos) Dr. Cosme Argerich, Buenos Aires 7 n General Emergency Medical Care System, Buenos Aires Direccio 1 2
A B S T R A C T
As part of the emergency medical care system, helicopter emergency medical services (HEMS) have a different crew composition from the traditional team. HEMS consist of a pilot, doctor, and firefighter with rescue skills and training in basic life support on board an air ambulance. This allows the adaptation to different environments and increases the varieties of air procedures normally performed. HEMS began operating relatively recently in Buenos Aires. Yet, in 3 years, its use grew to such an extent that in 2015 it tripled, and by 2016 the number of medical assists was 4 times greater than in 2014. Furthermore, over the 3-year study period, 92% to 95% of assisted victims were traffic accident casualties requiring primary care. The HEMS crew is informed about the availability of resources in the acute care general hospitals and can therefore transfer patients to the most appropriate trauma center in the shortest time. However, 75% to 85% of the time, the choice of destination is strongly influenced by the availability of a helipad and the operational safety that it provides. © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Approximately 1.2 million people worldwide die every year from traffic-related injuries, and the number of injured approaches 50 million.1 More than half of traffic collision fatalities are people 15 to 44 years old.1,2 Epidemiological data suggest a ratio of 1 death per 15 injuries requiring hospitalization, with more than 4-fold minor injuries.1,3 Efforts to reduce death rates and improve outcomes center on reducing time to medical aid and transport to a hospital.4-7 In addition, the management of injuries immediately after the collision is crucial to the victim's chances of survival and quality of later life.4,6,7 The Autonomous City of Buenos Aires (CABA) is located in the central-eastern region of Argentina on the western shore of the Rio de la ~ a 3250, 1107 Capi* Address for correspondence: Fernando Landreau, Avenida Espan tal Federal, Buenos Aires, Argentina E-mail address: [email protected] (F. Landreau). 1067-991X/$36.00 © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amj.2018.07.029
Plata. The last official census (2010) estimated its population at 2,890,151 or 14,391,538 when including its metropolitan area, making the city 1 of the 20 largest in the world.8 CABA's public health system serves 21.9% of the population, primarily through 34 public hospitals. Thirteen of these hospitals provide emergency and trauma care for the entire population of the city, meeting the definition of acute care general hospitals (HGAs).9 The emergency medical care system (SAME) is structured around HGAs, which serve as the bases of operations for ground ambulances, whose number depends on the size of each HGA catchment area. Ground ambulances must be able to respond to a "red code" emergency (lifethreatening) within 8 minutes and are supported by a telecommunications service. Ambulance crews are led by a doctor responsible for initial on-site attention and stabilization as well as in-transit care. Five HGAs are designated trauma centers and are staffed around the
368
F. Landreau et al. / Air Medical Journal 37 (2018) 367370
Table 1 Distribution by Type of Event of the Air Ambulance Operations With Transfer of Victims by an Emergency Medical Care System Sanitary Helicopter Between 2014 and 2016 2014 Type of Event 1: road traffic injuries
2: other causes of civil trauma
3: nontraumatic pathology
Traffic: motorbike Traffic: car Traffic: multiple collision Traffic: pedestrian No data Subtotal 1 High fall 3m Collapse/flattening Burned Subtotal 2 Cardiovascular Respiratory Neurologic Gastrointestinal Transplant Subtotal 3
No data Total
2015
2016
%
n
%
n
%
n
35.5 40.3 6.5 0.0 12.9 95.2 0.0 1.6 0.0 1.6 0.0 0.0 0.0 0.0 0.0 0.0 3.2 100.0
22 25 4 0 8 59 0 1 0 1 0 0 0 0 0 0 2 62
40.6 23.0 9.6 3.2 18.2 94.7 1.6 0.0 1.1 2.7 1.1 0.5 0.0 0.0 1.1 2.7 0.0 100.0
76 43 18 6 34 177 3 0 2 5 2 1 0 0 2 5 0 187
24.6 16.0 3.3 0.4 48.0 92.2 0.4 0.0 0.4 0.8 0.4 0.0 0.8 1.2 0.0 2.5 4.5 100.0
60 39 8 1 117 225 1 0 1 2 1 0 2 3 0 6 11 244
clock with a neurosurgeon; however, only 1 trauma center has a helipad, making it the preferred destination for all HEMS transfers. When necessary, landing on a public road is available at the other 4 trauma centers.10 Although urban distances within each HGA catchment area are short by design, these areas tend to be particularly prone to vehicular congestion and transportation delays (especially at certain times of the day). The reduction in transport times by HEMS has well-established and widely documented benefits.5,11,12 HEMS are designed to ensure a highly specialized rescue team, treatment initiation on-site, and minimization of delays in transporting victims to trauma centers. Also, HEMS crews receive regular updates on resource availability at all trauma centers to optimize response times, particularly in the event of a multiple-victim accident. Herein, we describe the utilization data of the CABA HEMS embedded in a network of public trauma centers and staffed with a unique crew configuration.
Materials and Methods The SAME HEMS started in CABA in December 2010 under contract, with a private provider (Flight Express SA, Modena Group, Buenos Aires, Argentina) furnishing aircraft (Bolkow-105 helicopters), pilots, and operating technicians, whereas the SAME provides physician staffing. Contract stipulations provide for the availability of 2 helicopters, 1 on active duty during daylight hours and the second as a backup. Meteorological conditions may limit aircraft operational
capacity, and the pilot has decision-making authority on flight conditions. The Bo-105 is a very small twin-engine, multipurpose, light utility helicopter, making it particularly suitable for operating in confined spaces such as urban areas. Unlike usual crew configurations in other countries,13,14 the SAME HEMS 3-member crews include a helicopter pilot and a physician with board certification in emergency medicine and additional qualifications in air evacuation by the National Institute of Air-Space Medicine. The third crew member is a firefighter with prehospital trauma life support certification and basic pilot training; if the pilot is disabled for any reason, he or she can make an emergency landing.15,16 The firefighter (designated herein as an operational technician) is a multitasking technician who usually works as a member of the medical crew but in emergency situations can assume a role as a member of the air crew. We reviewed daily operation logbooks for the SAME HEMS between January 1, 2014, and December 31, 2016, and summarized the distribution by type of event, diagnostic codes, basic victim demographics, and selection of the receiving trauma center.
Results The Argentine Civil Aviation Regulations x91 section L Application Standards for Sanitary Air Operations classifies medical air transport activities into 3 types, namely sanitary evacuation (ES), health air transportation service (STAS), and air transport of organs. ES refers to
Table 2 Distribution of Victims by Diagnostic Code of the Emergency Medical Care System 2014 Diagnostic Code 1 4 5 8 9 10 11 12 15 19 Total
Polytraumatism Mild traumatism Burned Hemorrhage Intoxications Cardiovascular Respiratory Digestive Neurologic Death
2015
2016
%
n
%
n
%
n
51.6 48.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0
32 30 0 0 0 0 0 0 0 0 62
64.5 31.2 1.1 0.0 0.5 1.6 0.5 0.5 0.0 0.0 100.0
120 58 2 0 1 3 1 1 0 0 186
47.8 46.6 0.8 0.4 0.0 0.4 0.0 1.2 1.2 1.6 100.0
119 116 2 1 0 1 0 3 3 4 249
F. Landreau et al. / Air Medical Journal 37 (2018) 367370
369
Table 3 Distribution by Sex and Age 2014 Sex
2015
Male
Female
2016
Male
Female
Male
Female
Age (y)
%
n
%
n
%
n
%
n
%
n
%
n
0-15 16-25 26-35 36-45 46-55 56-65 >66 No data Total
0.0 14.5 29.0 22.6 3.2 3.2 3.2 0.0 75.8
0 9 18 14 2 2 2 0 47
0.0 4.8 3.2 1.6 1.6 3.2 1.6 1.6 17.7
0 3 2 1 1 2 1 1 11
2.1 17.6 22.5 20.3 6.4 5.9 1.6 0.0 76.5
4 33 42 38 12 11 3 0 143
0.5 4.3 5.9 6.4 1.6 1.6 2.7 0.0 23.0
1 8 11 12 3 3 5 0 43
0.0 16.8 29.9 16.0 5.7 3.7 3.3 0.8 76.2
0 41 73 39 14 9 8 2 186
0.8 4.5 5.3 4.1 3.3 1.2 1.2 0.0 20.5
2 11 13 10 8 3 3 0 50
the transfer of a victim or a patient from the place of the incident to a health care center (primary transfer), whereas STAS refers to transfers between 2 medical centers (secondary transfer). The number of ES events increased over the 3 years of the study from 62 in 2014 to 187 in 2015 and 244 in 2016. Until recently, HEMS in Argentina was limited to STAS operations aimed at improving access from rural or mountain areas. The introduction of ES in the CABA area resulted from an expansion of the existing first response system. Emergency calls to the SAME operations center (by calling 107) are handled by operators who dispatch helicopters based on preestablished protocols. A medical coordinator at the air base in communication with the helicopter crew designates the receiving hospital and coordinates patient reception. Dispatch criteria of the SAME HEMS include accidents on urban highways with traffic congestion that makes it impossible for ground ambulances to reach the scene, events with multiple victims, incidents with trapped victims, or the transfer of organs for transplantation. Based on the type of incident, transfers are further classified as victims of vehicle trauma, nonvehicle trauma, and all others (Table 1). Victims of traffic-related trauma comprised over 90% of the total health helicopter transfers each year in the study period. There was no information on record for 2016 about the types of vehicles involved in 48% of traffic-related incidents, whereas for 2014 and 2015, 35.5% and 40.6%, respectively, were motorcyclists and 40.3% and 23.0%, respectively, were victims of car accidents with no distinction between the drivers and passengers. The largest number of victims transferred during the study period received a diagnostic of “polytraumatism,” whereas the second most
frequent diagnostic transfer code was “mild traumatism” (Table 2); these 2 diagnoses combined accounted for more than 90% of the HEMS transfer victims in the 3 years under study. Table 3 provides the distribution of the transported victims by age and sex. The overwhelming majority of the victims transferred by HEMS were taken to the trauma center at HGA Santojanni Hospital, the only center with a heliport on site. Most of the exceptions were burn victims or members of the police force who were generally transported to specialized centers (Table 4). Discussion Most of SAME HEMS operate on urban highways and involve victims of traffic-related trauma. When engaged, the HEMS crew is often the first responder to the incident. In these cases, the operative technician (firefighter) is responsible for environment safety and jointly with the doctor for victim extraction and placement on a long spinal board with a cervical collar and lateral immobilizers, which is locked to a fixation system on the floor of the aircraft. The doctor sits behind the passenger compartment, but because of lack of freedom of movement because of the position and reduced space of the cabin, advanced life support procedures such as endotracheal intubation, chest compressions, or thoracic drainage must be performed before boarding. Likewise, cardiac defibrillation cannot be performed in flight. Because flight times within CABA range from 5 to 15 minutes, the crew's physician must assess the patient's condition before takeoff. However, as shown in Table 2, a large proportion of victims transported by air sustained only mild traumatic injuries. This is because during peak hours, traffic congestion makes it impossible for ground ambulances to reach
Table 4 Distribution of Trauma Victims Transferred by an Emergency Medical Care System Medical Helicopter by the Receiving Medical Center 2014 Receiving Medical Center n Francisco Santojanni (GCABA) HGA Donacio HGA Dr. Cosme Argerich (GCABA) HGA Dr. Ignacio Pirovano (GCABA) HGA Dr. Juan A. Fernandez (GCABA) A. Penna (GCABA) HGA Jose Hospital de Quemados (GCABA) ~ os Dr. Ricardo Gutierrez (GCABA) Hospital de Nin Hospital de Pediatría SAMIC Prof. Dr. Juan Pedro Garrahan (MSN) dico Churruca Visca (PFA) Complejo Me HZGA Dr Narciso Lopez Lanus (GPBA) stor Kirchner (MSN) Hospital El Cruce SAMIC Dr Ne n Lucha contra las Enfermedades Neurolo gicas de la Infancia) FLENI (Fundacio Sin datos Total
2015
2016
%
n
%
n
%
n
75.8 8.1 6.5 4.8 0.0 0.0 0.0 0.0 3.0 0.0 0.0 0.0 1.6 100.0
47 5 4 3 0 0 0 0 2 0 0 0 1 62
83 8 2 0 0 0 1 1 4 0 1 1 0 100
155 15 4 0 0 0 1 1 7 0 2 1 0 187
84 10 0 0 1 0 0 2 3 0 0 0 0 100
206 24 1 0 2 1 0 1 8 1 0 0 0 244
GCABA = Government of the Autonomous City of Buenos Aires; GPBA = Government of the Province of Buenos Aires; HGA = General Hospital of Treble; HZGA = Zonal General Hospital of Treble; MSN = Ministry of Health of the Nation; PFA = Federal Police Argentina; SAMIC = Comprehensive Medical Care Service for the Community.
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the scene within the stipulated 8-minute time frame.17 In such cases, urgency is determined by the assessment of the severity of the victim's injuries.16,18 The age and sex distribution of the victims transferred by HEMS in CABA during the study period (Table 3) matches the published data for fatalities of traffic-related trauma victims.1,2 The choice of the HEMS referral hospital was heavily biased on the availability of a heliport at a single trauma center in CABA. This can be explained by the operational safety of the crew and patients. Landing on city streets requires coordination with a ground ambulance from the hospital and traffic police officers on the ground to ensure public safety.16 Reasons identified on the log for deviating from this preference included the lack of trauma beds at HGA Santojanni Hospital and the presence of burns (requiring specialized care) or uniformed police victims (transferred to the police hospital). Our data cover the daylight operations conducted by HEMS within the CABA catchment area. Summary In summary, this article describes the performance of HEMS operating exclusively within a congested urban setting, the basic characteristics of the victims evacuated by helicopter, and the medical crew's choice of referral target. Unfortunately, we did not have access to the clinical outcome data of the transported victims, which would have provided useful information. Acknowledgment n Ladaga for help editThe authors thank Dana Martinez and Bele ing the text and Dr. Gabriel A. de Erausquin for his advice, helpful discussions, and revision of the manuscript. Supplementary materials Supplementary data related to this article can be found at https:// doi.org/10.1016/j.amj.2018.07.029. References n de 1. World Health Organization and World Bank. Informe Mundial Sobre Prevencio nsito: Resumen. Geneva, Switzerland: Organlos Traumatismos Causados por el Tra n Mundial de la Salud; 2004. izacio
2. de Vigilancia B. Enfermedades no transmisibles y factores de riesgo. Boletín Epidegico. 2011. 6-1727-31. miolo ~ os potenciales de vida perdidos (APVP): una medida 3. Dranger E, Remington P. An que resume la mortalidad prematura para evaluar la salud de las comunidades. Wisconsin Public Health Policy Institute Brief. 2004;5:7. 4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support, ATLS. 9th ed., 2016 The Journal of Trauma and Acute Care Surgery. 74 (5):13636, May 2013. https://doi.org/10.1097/TA.0b013e31828b82f5. 5. Abbasi H, Bolandparvaz S, Yadollahi M, Anvar M, Farahgol Z. Time distribution of injury-related in-hospital mortality in a trauma referral center in South of Iran (2010-2015). Medicine (Baltimore). 2017;96:e6871. 6. Alarhayem AQ, Myers JG, Dent D, et al. Time is the enemy: mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”. Am J Surg. 2016;212:1101–1105. 7. Neira J, Tisminetsky G. Atencion Inicial de Pacientes Traumatizados. Buenos Aires, Argentina: Fundacion Pedro Luis Rivero; 2010. n, 8. Edwin AM. Instituto Nacional de Estadística y Censos. Censo Nacional de Poblacio Hogares y Viviendas 2010. Serie B. Buenos Aires, Argentina: Instituto Nacional de Estadística y Censos; 2012. n porcentual de la poblacio n 9. Estadisticas y Censos, Buenos Aires Ciudad. Distribucio dica segu n comuna. Ciudad de Buenos Aires. An ~ os 2006/ por tipo de cobertura me 2016, 2016. 10. http://www.buenosaires.gob.ar/noticias/sistema-de-atencion-medica-de-emergencia. Accessed oficial website of the government of the Autonomous City of Buenos Aires. 11. Brown JB, Gestring ML, Guyette FX, et al. Helicopter transport improves survival following injury in the absence of a time-saving advantage. Surgery. 2016;159:947–959. 12. Dharap SB, Kamath S, Kumar V. Does prehospital time affect survival of major trauma patients where there is no prehospital care? J Postgrad Med. 2017;63:169– 175. 13. Cardoso RG, Francischini CF, Ribera JM, Vanzetto R, Fraga GP. Helicopter emergency medical rescue for the traumatized: experience in the metropolitan region of Campinas, Brazil. Rev Col Bras Cir. 2014;41:236–244. 14. Abe T, Takahashi O, Saitoh D, Tokuda Y, Daly MJ, et al. Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan. 2010. Critical Care. 2014 Jul 9;18 (4):R146. https://doi.org/10.1186/cc13981. 15. Wilson S, Gangathimmaiah V. Does prehospital management by doctors affect outcome in major trauma? A systematic review. J Trauma Acute Care Surg. 2017;83:965–974. 16. Zalstein S, Cameron PA. Helicopter emergency medical services: their role in integrated trauma care. Aust N Z J Surg. 1997;67:593–598. 17. Weerheijm DV, Wieringa MH, Biert J, Hoogerwerf N. Optimizing transport time from accident to hospital: when to drive and when to fly? ISRN Emerg Med. 2012;2012:1–5. 18. Wilson A, Cross F. Helicopters. J R Soc Med. 1992;85:1.