Outcomes of Physician-Staffed Versus Non-Physician-Staffed Helicopter Transport for ST-Elevation Myocardial Infarction

Safety and Adverse Events During Primary Care Paramedic Interfacility Transfer of Stable STEMI Patients

OBJECTIVE

Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 min. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available. Our goal was to describe adverse events and need for advanced interventions among initially stable STEMI patients during interfacility transfer by PCPs.

METHODS

We reviewed ambulance and hospital records of initially stable STEMI patients (as determined by first set of vital signs documented by paramedics) transferred to a PCI-capable hospital by PCPs between March 1, 2014, and December 31, 2019. We identified whether pre-determined adverse clinical events occurred during the transport as well as the potential need for advanced care interventions not within the PCP scope of practice. Adverse events upon arrival in the PCI lab were also identified.

RESULTS

Of 346 STEMI patients transferred, 179 met inclusion criteria. The mean age of included patients was 61 years (SD 12.1) and 74.9% (134/179) were male. Median transport interval was 36 min (IQR 3.0). During transport, 47/179 (26.0%) patients experienced pre-defined adverse events; for 16/47 (34%), one or more adverse events was major. Three patients met criteria for ACP interventions. One patient suffered a cardiac arrest and was promptly resuscitated with defibrillation by the PCPs.

CONCLUSIONS

We found PCP-interfacility transport of initially stable STEMI patients was safe and associated with a moderate proportion of adverse events, the majority of which did not require an advanced care intervention. These findings may help decision-making to avoid delays transferring stable patients to PCI-capable centers.

The Value of Physicians as Part of a Helicopter Emergency Medical Services Crew: A Review

OBJECTIVE

The benefit and utility of a physician on a US-based air ambulance is an often-debated topic in the prehospital setting. There remains the question of what, if any, effect a physician crewmember has on patient outcome. Our goal was to assess the literature to date and determine if there exists a benefit to staffing air ambulances with physicians.

METHODS

PubMed and Cochrane databases were searched for English language studies from 1980 to 2020 using the terms "flight physician" and "physician-staffed helicopter." Studies were chosen for inclusion based on the presence of a comparison of physician-staffed crews with non-physician-staffed crews. The included studies had their references reviewed for additional studies meeting the inclusion criteria.

RESULTS

A total of 19 articles were included, and their overall opinion of the benefit of a physician was assessed. Ten studies demonstrated a benefit, 8 showed no benefit or favored a nonphysician crew, and 1 was equivocal.

CONCLUSIONS

Although some studies showed a benefit to having physicians staff an air ambulance, some showed no benefit, leaving our findings inconclusive. More data are needed to determine if the inclusion of these crewmembers has a positive effect on patient outcomes.

Predictors for in-flight medical interventions during helicopter interfacility transport in Hong Kong

Introduction:

Interfacility transport with helicopter from remote island clinics to urban hospitals account for a significant portion of the Hong Kong Government Flying Service missions. Currently, doctor and nurse escorts are deployed as volunteers only during the daytime from every Friday to Monday and on public holidays. While most transport runs smoothly, patient deterioration can occur during flight, warranting medical interventions on-board. Yet, little is known about the pattern and any clinical predictors of such interventions during helicopter interfacility transport missions.

Methods:

We collected Government Flying Service callout records from 1 January to 31 December 2016, and retrieved demographic, clinical and operational data. Interfacility transport mission was dispatched based on ‘Casualty Evacuation’ categories, which range from A+ (unstable), A (borderline) to B (stable). Univariate and multivariable logistic regression were used to identify independent predictors for in-flight medical interventions.

Results:

Of 1734 callout records, 386 interfacility transport missions escorted by volunteer doctors or nurses or both had complete flight medical records for analysis and 14.9% required in-flight medical interventions. Most interventions were related to oxygen therapy, intravenous fluid and administration of medications. Multivariable logistic regression showed that an age ⩾70 years, Casualty Evacuation A+ category, and any pre-flight emergency medical interventions were independent predictors for in-flight medical interventions.

Conclusion:

This study identified a few clinical predictors of in-flight medical interventions in an urban helicopter interfacility transport missions setting. Crewman training that focuses on the relevant procedural capabilities and clinical judgement is necessary to address the in-flight medical needs of interfacility transport missions.

A physician-staffed ground emergency medical service does not significantly shorten door-to-balloon time in patients with STEMI: an observational study in a single emergency center in Japan

Aim

Current guidelines recommend a door‐to‐balloon time (DTBT) of <90 min for reperfusion treatment of patients with ST‐segment elevation myocardial infarction (STEMI). A physician‐staffed ground emergency medical service (GEMS) using a rapid response car (RRC) system was implemented at our hospital in April 2015. The medical team, including a physician and nurse, is dispatched to assess the patient and expedite the start of treatment by emergency physicians and cardiologists after arrival at the hospital. The study aimed to determine whether the RRC system shortened the DTBT.

Methods

This retrospective observational study was carried out in a tertiary emergency center in Japan. Those STEMI patients with primary percutaneous intervention between January 2016 and December 2018 were evaluated. The DTBTs of patients transported by the RRC system, the emergency medical service (EMS), and transferred from other hospitals after STEMI diagnosis (TRANS group) were compared.

Results

A total of 121 patients were included, 33 in the RCC, 20 in the EMS, and 68 in the TRANS groups. The median DTBT was 51 min (interquartile range [IQR], 43–67) in the RRC, 61 min (IQR, 52–85) in the EMS, and 59 min (IQR, 48–72) in the TRANS groups (P = 0.13). The DTBT was not significantly shorter in the RRC than in the other groups.

Conclusion

An RRC physician‐staffed GEMS did not significantly shorten the DTBT of patients with STEMI compared with other transport systems.

Impact of Physician-staffed Helicopters on Pre-hospital Patient Outcomes: A systematic review

BACKGROUND

Management of pre-hospital patients remains a challenge. In developed countries a physician-staffed helicopter emergency medical service (PS-HEMS) is used in addition to ground emergency medical service (GEMS), but the effect is debated. This systematic review aimed to evaluate the effect of PS-HEMS compared with GEMS on patient outcomes based on the published scientific literature.

METHODS

Medline, EMBASE and the Cochrane Library were systematically searched on November 15, 2019 for prospective, interventional studies comparing outcomes of patients transported by either PS-HEMS or GEMS. Outcomes of interest were mortality, time to hospital and quality of life.

RESULTS

The majority of 18 studies included were observational and difficult to summarize because of heterogeneity. Meta-analysis could not be carried out. Three studies found reduced mortality in patients transported by PS-HEMS compared with GEMS with Odds ratios (OR) of 0.68 (0.47-0.98); 0.29 (0.10-0.82) and 0.21 (0.06-0.73) respectively. Another two studies found improved survival with OR 1.2 (1.0-1.5) and 6.9 (1.48-32.5) in patients transported by PS-HEMS compared with GEMS. In three studies, PS-HEMS was associated with shorter time to hospital. Three studies reported quality of life and found no benefit of PS-HEMS.

CONCLUSION

In this systematic review the studies comparing PS-HEMS with GEMS were difficult to summarize because of heterogeneity. We found a possible survival benefit of PS-HEMS but were unable to conduct a meta-analysis. The overall quality of evidence was low.

A Report Concerning Collaboration Between a Physician-staffed Helicopter (Doctor Helicopter) and Firefighting/Rescue Helicopter

OBJECTIVE

In Japan, the main helicopters that transport patients are physician-staffed helicopters (known as doctor helicopters [DHs]) and firefighter/rescue helicopters (F/RHs). We report the collaboration between F/RHs and DHs in eastern Shizuoka Prefecture.

METHODS

We retrospectively investigated all of the patients who were transported by F/RHs in Shizuoka Prefecture between January 2015 and April 2018.

RESULTS

Nine cases were defined as subjects. Seven subjects had suffered trauma, 1 decompression illness, and 1 intrinsic disease. Seven of the 9 subjects were rescued from the bottom of a cliff or shore reef, and all 7 were transferred from an F/RH to a DH at the rendezvous zone near the rescue scene. One of the 9 subjects was a mass casualty event, and the remaining patient was rescued and directly transported to our hospital by an F/RH. All but 1 who was in cardiac arrest at the scene survived.

CONCLUSION

Because relatively few subjects were managed via collaboration between an F/RH and a DH in eastern Shizuoka Prefecture, further studies will be required to investigate whether or not such a collaboration is useful for improving the outcome of sick and wounded patients.