Helicopter Emergency Medical Service Units Research Articles

The creation, implementation, and harmonisation of medical standard operating procedures and checklists of Finnish Helicopter Emergency Medical Service units

IntroductionThe purpose of this study was to investigate the creation, implementation, and harmonisation of medical Standard Operating Procedures (SOP) in Finnish Helicopter Emergency Medical Services (HEMS). The research questions are: (1) What factors influence the creation and implementation of medical SOPs for Finnish HEMS units? and (2) What can be done to harmonise the medical SOPs of Finnish HEMS units?MethodsThe research was conducted as a qualitative interview study with HEMS physicians who worked full-time in Finnish HEMS units or had worked in HEMS for more than five years. Three HEMS physicians from each of the six HEMS units in Finland participated in the study (n = 18). The thematic interviews (average duration 32 min) were transcribed (70,176 words in Finnish) and analysed using inductive content analysis.ResultsThe results of the first research question formed three main categories: (1) Background to developing medical SOPs and checklists (CLs), (2) Creation of medical SOPs in Finnish HEMS units, and (3) Implementation of medical SOPs and CLs. The main categories were divided into eight upper categories and twelve subcategories. The results of the second research question formed four main categories: (1) Prerequisites for harmonising procedures, (2) System-level changes needed, (3) Integrating common medical SOPs into HEMS, and (4) Cultural change. The main categories were divided into nine upper categories and nine subcategories.ConclusionsMedical SOPs and CLs are an integral part of Finnish HEMS. Each unit creates its own SOPs and CLs; their development, implementation, and follow-up are relatively unstructured. Harmonising existing SOPs would be possible, but developing common SOPs would require structural changes in HEMS and a stronger sense of community belonging among HEMS physicians.

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services

BackgroundSeverity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm.MethodsWe conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets.ResultsAfter exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023).ConclusionsBased on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Differential diagnosis and cause-specific treatment during out-of-hospital cardiac arrest: a retrospective descriptive study

BackgroundThe cardiopulmonary resuscitation (CPR) guidelines recommend identifying and correcting the underlying reversible causes of out-of-hospital cardiac arrest (OHCA). However, it is uncertain how often these causes can be identified and treated. Our aim was to estimate the frequency of point of care ultrasound examinations, blood sample analyses and cause-specific treatments during OHCA.MethodsWe performed a retrospective study in a physician-staffed helicopter emergency medical service (HEMS) unit. Data on 549 non-traumatic OHCA patients who were undergoing CPR at the arrival of the HEMS unit from 2016 to 2019 were collected from the HEMS database and patient records. We also recorded the frequency of ultrasound examinations, blood sample analyses and specific therapies provided during OHCA, such as procedures or medications other than chest compressions, airway management, ventilation, defibrillation, adrenaline or amiodarone.ResultsOf the 549 patients, ultrasound was used in 331 (60%) and blood sample analyses in 136 (24%) patients during CPR. A total of 85 (15%) patients received cause-specific treatment, the most common ones being transportation to extracorporeal CPR and percutaneous coronary intervention (PCI) (n = 30), thrombolysis (n = 23), sodium bicarbonate (n = 17), calcium gluconate administration (n = 11) and fluid resuscitation (n = 10).ConclusionIn our study, HEMS physicians deployed ultrasound or blood sample analyses in 84% of the encountered OHCA cases. Cause-specific treatment was administered in 15% of the cases. Our study demonstrates the frequent use of differential diagnostic tools and relatively infrequent use of cause-specific treatment during OHCA. Effect on protocol for differential diagnostics should be evaluated for more efficient cause specific treatment during OHCA.

Air Medical Support for a Peripheral Hospital in Southern Israel: An Evolving Role for the Air Ambulance and Emergency Department Clinicians

The early use of helicopters on the battlefields of Korea and Vietnam led to the introduction of “air ambulances” into civilian practice. Initially, these aircraft were tasked to retrieve casualties and provide conventional paramedic care at the scene and en route to the hospital. The introduction of advanced medical teams on helicopters led to the evolution of helicopter emergency medical service units. Yoseftal Hospital is a 65-bed hospital serving the town of Eilat in southern Israel. It does not offer full intensive care or specialist services but does provide general surgical, medical, pediatric, and psychiatric services. The hospital is 100 km from the nearest tertiary center in Be'er Sheva, an ambulance journey of 2 hours across desert. The hospital serves a population of 70,000 residents and up to 500,000 tourists. Recognizing the need to provide a facility to transfer critical or complex patients, in August 2021, the Israeli Ministry of Health provided a dedicated helicopter to Yoseftal Hospital. The first 100 missions are presented. Forty-four missions were for cardiac presentations. For patients with ST-segment elevation myocardial infarction, the median time from the initial medical contact at Yoseftal to reception at the tertiary center was 141 minutes. Other transfers were for ear, nose, and throat (2); neurosurgical (14); trauma (9); respiratory (6); obstetrics and gynecology (3); and pediatric services (14) and nontraumatic surgical emergencies (15). Our experience validates the need for this resource and highlights the importance of robust clinical, operational, and transfer protocols between Yoseftal and the receiving specialist units. The challenging and diverse clinical activity requires additional skills and competencies for the critical care paramedics on the aircraft. Integrating the flight crew into the emergency department team facilitated early activation of the aircraft and expedited patient preparation for flight. Our experience describes an evolving new role for the helicopter—support for a remote peripheral hospital.

Reasons behind failed prehospital intubation attempts while combining C-MAC videolaryngoscope and Frova introducer.

High first-pass success rate is achieved with the routine use of C-MAC videolaryngoscope and Frova introducer. We aim to identify potential reasons and subgroups associated with failed intubation attempts, analyse actions taken after them and study possible complications. We conducted a retrospective observational study of adult intubated patients at a single helicopter emergency medical service unit in southern Finland between 2016 and 2018. We collected data on patient characteristics, reasons for failed attempts, complications and follow-up measures from a national helicopter emergency medical service database and from prehospital patient records. 1011 tracheal intubations were attempted. First attempt was successful in 994 cases (FPS 994/1011, 98.3%), 15 needed a second or third attempt and two a surgical airway (non-FPS 17/1011, 1.7%, 95% CI 1.0-2.7). The failed first attempt group had heterogenous characteristics. The most common cause for a failed first attempt was obstruction of the airway by vomit, food, mucus or blood (10/13, 76%). After the failed first attempt, there were six cases (6/14, 43%) of deviation from the protocol and the most frequent complications were five cases (5/17, 29%) of hypoxia and four cases (4/17, 24%) of hypotension. When a protocol combining the C-MAC videolaryngoscope and Frova introducer is used, the most common reason for a failed first attempt is an airway blocked by gastric content, blood or mucus. These findings highlight the importance of effective airway decontamination methods and questions the appropriateness of anatomically focused pre-intubation assessment tools when such protocol is used.

Frequency, indications and success of out-of-hospital intubations in Finnish children.

Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). We conducted a retrospective observational cohort study in Finland including all children less than 16years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1year, 103 were aged 1-5years and 120 were aged 6-15years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5years and trauma for those aged 6-15. The HEMS physicianshad an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p=.002) and for patients in cardiac arrest (p<.001). Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.

Pre-hospital critical care management of severe hypoxemia in victims of Covid-19: a case series

ObjectiveDespite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support.MethodsThree cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist.Patient’s next of kin and the Regional committee for medical and health research ethics approved the publication of this report.ConclusionPatients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient’s ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO2. Finally, assuming the patient is cooperative, repositioning to prone position.

Association of Helicopter vs Ground Emergency Medical Transportation With 1-Year Mortality in Denmark

Appropriate use of helicopter emergency medical service (HEMS) is important in ensuring that patients with critical illness or injury receive adequate treatment. To investigate the association between use of HEMS compared with use of ground EMS (GEMS) and mortality overall and in a subgroup of patients with critical illness or injury. This register-based, nationwide cohort study used data retrieved from Danish registries from October 1, 2014, to April 30, 2018. Patients receiving GEMS originated from dispatched HEMS missions for which a helicopter was unavailable. For the primary analysis, patients from accepted HEMS missions and patients from missions in which HEMS was dispatched but unavailable were included. The secondary analysis included patients assigned a hospital International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis considered a critical illness or injury. These patients were selected via a consensus-based agreement among all authors by reviewing the Danish version of the World Health Organization's ICD-10 classification. Data were analyzed from March to June 2020. Dispatch of HEMS vs GEMS unit (primary analysis) and treatment and transport by HEMS vs GEMS unit among patients with critical illness or injury (secondary analysis). One-year mortality was retrieved from the Danish Civil Registration System. Among 10 618 patients (median [interquartile range] age, 60 [42-72] years; 6834 [64.4%] men) included in the primary analysis, 9480 patients (89.3%) received HEMS and 1138 patients (10.7%) received GEMS. Median (interquartile range) age was 60 (42-72) years, and 6834 patients (64.4%) were men. Adjusted cumulative 1-year mortality was 23.2% (95% CI, 22.4%-24.1%) among patients receiving HEMS vs 24.5% (95% CI, 21.9%-27.1%) among patients receiving GEMS. The difference in mortality risk for HEMS compared with GEMS was not statistically significant (hazard ratio, 0.94 [95% CI, 0.84-1.06]). Among 2260 patients with critical illness or injury receiving HEMS, compared with 315 patients with critical illness or injury receiving GEMS, adjusted cumulative 1-year mortality was 25.1% (95% CI, 23.5%-26.7%) vs 27.1% (95% CI, 22.0%-32.1%). The difference in mortality risk for HEMs compared with GEMs was not statistically significant (hazard ratio, 0.91 [95% CI, 0.73-1.14]). This study found that 1 year after dispatch, the use of HEMS, compared with the use of GEMS, was not associated with a statistically significant difference in mortality overall or mortality among patients with critical illness or injury. Further research is needed to determine whether optimized dispatch systems may be associated with further improvements in survival among selected patients.

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure.

AimTo illustrate the pre‐hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre‐hospital conditions.Methods and resultsA multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre‐hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated.Ultrasound devices and point‐of‐care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST‐elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12‐lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point‐of‐care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non‐invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST‐elevation myocardial infarction, asthma, and stroke.ConclusionsThe prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre‐hospital conditions.

Defining a mission-based method to determine a HEMS unit\u2019s actual service area

BackgroundGeographical service areas are used as descriptive system indicators in Emergency Medical Service (EMS) related studies and reporting templates. The actual service area may differ significantly from administrative areas; this may lead to inaccuracy in determining indicator values, such as population or mission density, thus making it biased when comparing results between different areas and organizations.The aim of this study was to introduce a univocal, repeatable and easily adaptable method to determine the actual service area of a helicopter emergency medical service (HEMS) unit for statistical, quality measurement and research purposes using widely available geographical information (GIS) and statistical analysis tools.MethodsThe method was first tested with Tampere HEMS unit. All accepted missions in 2017 were extracted from FinnHEMS database (FHDB). We calculated distance from HEMS base to each accepted mission location. Missions were reordered based on the distance and 99th and 95th percentiles were calculated for mission distances. Convex hulls including 100, 99 and 95% of the missions, and the population and area covered by these missions, were then calculated. The method was repeated for all Finnish HEMS bases.ResultsApproximately 90% of Tampere HEMS unit’s accepted missions took place within 100 km from the base. 10.9% of the missions occurred outside of the administrative service area. 95% convex hull areas are most in line with the everyday experience of where the units actually operate. In Tampere, the 95% convex hull area corresponds to 76,5% of the administrative area’s population and to 89,8% of its area. Calculating the 95% convex hull areas for all Finnish HEMS units results in service areas that overlap at some points, and some areas of the country fall outside of all HEMS service areas.ConclusionsAdministrative areas do not correspond to the actual service areas of HEMS units. The service area of a HEMS unit defined by administrative boundaries may differ significantly from actual operations. Using historical mission data to create a convex hull that incorporates mission locations could offer a standardized and comparable solution for determining actual HEMS unit service areas, which can be used for statistical comparison, quality measurement and system development.

Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

BackgroundAfter traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients.MethodsThis was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4–5.ResultsData from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome.ConclusionThe introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period.Trial registrationClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.

Role of Polish Medical Air Rescue in national medical rescue system

Great technological progression, as well as the development of motorization in the past decades, has caused an intensification of danger to health and life for contemporary societies. The increasing amount of HEMS (Helicopter Emergency Medical Service) units interventions underline that the significance of the Polish Med­ical Air Rescue service within the structures of National Medical Rescue System is increasing. Polish Medical Air Rescue is the one and only organization in Poland which uses helicopters while performing emergency medical services and conducting the transport of patients. The history of medical aviation, and later the Polish Medical Air Rescue service shows the great work and effort that has been put into the development and functioning of this organization.

Utilisation of a Helicopter Emergency Medical Service (HEMS) for equestrian accidents in a regional major trauma network in the United Kingdom

IntroductionThe utilisation of Helicopter Emergency Medical Services (HEMS) in response to equestrian accidents has been an integral part of operations for many years throughout the UK. The recent establishment of major trauma networks in the UK has placed great emphasis on the appropriate tasking of HEMS units to cases where added benefit can be provided and the incidence of time critical injury in cases of equestrian accidents has been shown to be low. This study assesses the impact made on the utilisation of the different HEMS resources for cases of equestrian accidents within the West Midlands following the launch of the regional trauma network. MethodsWe present a retrospective analysis of all equestrian accidents attended by Midlands Air Ambulance (MAA) between 1 April 2012 and 1 April 2013. Data were abstracted from the MAA operational database relating to mission activations/scene attendances; team configuration (physician led and Critical Care Paramedic (CCP) led); on-scene interventions; mission timings and patient conveyance by helicopter. ResultsA total of 114 activations involved equestrian accidents (6% of overall workload). The contribution of equestrian accidents to overall workload was similar for physician led and CCP-led (69/1069) platforms (5% vs. 6%, p=0.50). Only three patients (3%) required pre-hospital RSI during the period analysed and there were no recorded cases of ketamine administration for analgesia/conscious sedation. In approximately half of all scene attendances patients did not require any medication to be administered by the HEMS team. The vast majority of incidents occurred in rural locations with over 80% of patients conveyed to hospital by helicopter.The average mission time for scene attendances resulting in conveyance by helicopter was in excess of 90min on both types of platform. ConclusionsThere is a clear requirement for the design and implementation of informed and intelligent tasking models to respond to the need for assistance in equestrian accidents. Such models may include preferential deployment of non-physician led HEMS resources to equestrian accidents or the utilisation of other local or regional resources, such as those with specially adapted vehicles with off road capability, to offer alternative solutions to access/egress challenges posed in such cases.

In-Flight Breech Delivery in Finnish Lapland

Although medical crews may initially approach obstetric transport requests with (at least internal) trepidation, it has been shown that the risk of an in-flight delivery occurring is extremely low, even among patients considered high risk.1–4 Nevertheless, the greatest concern of helicopter emergency medical service (HEMS) personnel remains the potential for in-flight delivery.5Finland is a Northern European country, with a land area almost equivalent to that of the US state of New Mexico. The Finnish HEMS system is managed by FinnHEMS, and there are 6 HEMS units in Finland. The northernmost HEMS unit, FinnHEMS 51, is based at Rovaniemi Airport in Finnish Lapland, which is located within the Arctic Circle; it operates over a remote and sparsely habited area. Finnish Lapland accounts for almost 30% of Finland by area; however, the density of population is low (only 2.0 persons per square kilometer), and the average annual year-round temperature is only —1°C (30°F).6 So far, there has been only 1 reported in-flight delivery; in 1939, a baby girl was born in an airplane operated by the Finnish Border Guard.7

Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback

Context Automated verbal and visual feedback improves quality of resuscitation in out-of-hospital cardiac arrest and was proven to increase short-term survival. Quality of resuscitation may be hampered in more difficult situations like emergency transportation. Currently there is no evidence if feedback devices can improve resuscitation quality during different modes of transportation. Objective To assess the effect of real time automated feedback on the quality of resuscitation in an emergency transportation setting. Design Randomised cross-over trial. Setting Medical University of Vienna, Vienna Municipal Ambulance Service and Helicopter Emergency Medical Service Unit (Christophorus Flugrettungsverein) in September 2007. Participants European Resuscitation Council (ERC) certified health care professionals performing CPR in a flying helicopter and in a moving ambulance vehicle on a manikin with human-like chest properties. Interventions CPR sessions, with real time automated feedback as the intervention and standard CPR without feedback as control. Main outcome measures Quality of chest compression during resuscitation. Results Feedback resulted in less deviation from ideal compression rate 100 min −1 (9 ± 9 min −1, p < 0.0001) with this effect becoming steadily larger over time. Applied work was less in the feedback group compared to controls (373 ± 448 cm × compression; p < 0.001). Feedback did not influence ideal compression depth significantly. There was some indication of a learning effect of the feedback device. Conclusions Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.