Cross-sectional investigation of HEMS activities in Europe: a feasibility study

Loss of consciousness in a helicopter pilot as plausible first sign of insulinoma: a case report

A 50-year-old man who worked as a helicopter rescue pilot transiently lost consciousness while piloting a helicopter rescue. In the diagnostic process, all tests for the main possible differential diagnoses of loss of consciousness (cardiological and neurological) were performed and yielded normal results. Blood chemistry tests revealed recurrent fasting hypoglycemia and Chromogranin A was at the upper limit of normal. Fine needle aspiration guided by endoscopic ultrasonography was used to diagnose insulinoma-type neuroendocrine tumor of the pancreas. According to the Italian policies, the occupational physician aims to maintain professional skills without neglecting flight safety. A careful analysis of the relationship between the characteristics of the state of health of the aviator and his specific work needs was carried out, and he was given the opportunity to continue working as a rescue pilot thanks to medical therapies associated with organizational interventions in the workplace.

Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update

BACKGROUND

Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS.

METHODS

A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts.

RESULTS

Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template.

CONCLUSIONS

Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway

BACKGROUND

Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template.

METHODS

The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties.

RESULTS

All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method.

CONCLUSIONS

We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Changes in anaesthetic use for trauma patients in German HEMS - a retrospective study over a ten-year period

Background

Airway management and use of intravenous anaesthetics to facilitate tracheal intubation after major trauma remains controversial. Numerous agents are available and used for pre-hospital rapid-sequence induction (RSI). The aim was to investigate usage and potential changes in administration of intravenous anaesthetics for pre-hospital RSI in trauma patients over a ten-year period.

Methods

Based on a large helicopter emergency medical service (HEMS) database in Germany between 2006 and 2015, a total of 9720 HEMS missions after major trauma leading to RSI on scene were analysed. Administration practice of sedatives and opioids were investigated, while neuromuscular blocking agents were not documented in the database.

Results

With respect to administration of sedatives, independent from trauma mechanism and specific injury patterns the use of Etomidate decreased dramatically (52 to 6%) in favour of a more frequent use of Propofol (3 to 32%) and Ketamine (9 to 24%; all p < 0.001) from 2006 to 2015. The use of Benzodiazepines increased slightly, while the utilization rate of Barbiturates remained constant. In patients with Shock Index > 1 at initial contact, the administration rate of Etomidate dropped significantly as well. This decline was mainly substituted by Ketamine and particularly Propofol. In patients with GCS ≤ 8 upon initial contact, a similar distribution compared to the general trauma population could be observed.

With respect to opioids, mainly Fentanyl has been administered for RSI in trauma patients (2006: 69,6% to 2015: 60.2%; p < 0.001), while the use of sufentanyl showed a significant increase (0.2 to 8.8%; p < 0.001).

Conclusions

This large study analysed prehospital administration of anaesthetics in trauma patients, showing a substantial change from 2006 to 2015 despite the lack of any high-level evidence. Etomidate has shifted from the main sedative substance to virtual absence, indicating that the recommendation of an established national guideline was transferred into clinical practice, although based on weak evidence as well. The pre-hospital use of Propofol showed a particular increase. Fentanyl has been the main opioid drug for RSI in trauma, however Sufentanyl has become increasingly popular. The mechanisms and advantages of the different substances still have to be elucidated, especially in head injury and bleeding trauma.

Physician-provided prehospital critical care, effect on patient physiology dynamics and on-scene time

INTRODUCTION

Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions.

MATERIALS AND METHODS

Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2), (MEES 2-MEES 1=[INCREMENT]MEES).

RESULTS

A total of 240 primary missions with patient-on-scene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using [INCREMENT]MEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved.

CONCLUSION

Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service

OBJECTIVE

There is little current evidence regarding which therapeutic agents are actually used within existing aeromedical services. The Greater Sydney Area Helicopter Emergency Medical Service operates a large, physician-staffed, multimodal, prehospital and interhospital retrieval service. The aim of the present study was to identify the range and frequency of drug, fluid and blood product use within our service.

METHODS

This was a retrospective cross-sectional study. Case sheets relating to a 12 month period were inspected to identify the therapeutic agents used by retrieval teams during each mission. Corresponding case notes, demographic data (age, sex) and case data (prehospital vs interhospital, trauma vs medical) were extracted from an electronic database.

RESULTS

Of 2566 missions, 848 were prehospital, 1662 interhospital and 56 mixed. Prehospital missions were associated with fewer agents per case (median, 2 vs 3) and a narrower range of agents overall (45 vs 117) compared to interhospital missions. In both mission types, the most frequently used agents included morphine, fentanyl, Hartmann's solution, ketamine, rocuronium, ondansetron and midazolam. Noradrenaline, propofol and metaraminol were used frequently in interhospital missions only. A number of stocked and unstocked agents were used less commonly, or not at all, over the study period.

CONCLUSIONS

The results of the present study form a practical guide to aid prehospital and retrieval services in establishing or reviewing their medical agent formularies. Key practice points illuminated by the data provide insights into current practice in critical care. There remains a clear need for similar studies from other services worldwide.