How many "Rescue" Helicopters does New Zealand need?
Blair Munford
Outline
How many “Rescue” Helicopters
does New Zealand need?
Blair Munford, FANZCA
Senior Flight Physician & former Medical Director
NRMA CareFlight/NSW Medical Retrieval Service
Westmead Hospital, Sydney, Australia
I can't answer that question.
WHY NOT?
BECAUSE . . . THE QUESTION ITSELF CANNOT BE ANSWERED IN ISOLATION
Current NZ situation
This must be good, right?
Well, maybe not . . .
A cautionary tale:
(Sad, but true)
Report from NZ provincial daily newspaper
Farm accident: unconscious patient in ravine
Regional rescue helicopter responded
Clinical crew: single ambulance officer
No on-scene medical stabilisation
Patient manhandled into aircraft at hover!
No in-flight medical stabilisation
Flown to local provincial hospital
Sad, but true :
(Continued)
At provincial hospital intubated & ventilated
CT scan: sub-dural haematoma
Loaded back into rescue helicopter
Flown to regional trauma centre
– Which has dedicated medical helicopter with rescue hoist & physician/paramedic crew
– Which was actually closer in a straight line to accident site than the regional rescue helicopter
SDH drained: made incomplete recovery
Helicopters are intrinsically photogenic . . .
. . . but not intrinsically therapeutic!
“But why is this so?”
- Julius Sumner Miller
Ad hoc establishment of services
- from large pool of general aviation helicopters
- with assumption that any helicopter makes a good air ambulance.
Not coordinated with overall trauma or critical care planning
Varying clinical standards
Community xenophobia
“Show me the money”
- Cuba Gooding, Jr (“Jerry Maguire”)
Financial Issues
Utilisation based reimbursement
Low or no standing/establishment funding
Commercial helicopter providers
RESULT:
“TAXICAB OPERATING PHILOSOPHY”
But above all:
Shortage of quality local evidence:
Outcome based studies
Class 1, 2 or 3 studies
Even class 4 recommendations
Abundance of “Class 7” evidence
(Class 7 Evidence: “Media reports of the unsolicited opinions of morons with a conflict of interest”)
-Tony Smith, 2004
Helicopters do not save lives in trauma
Trauma systems that utilise
helicopters appropriately do
A helicopter equipped and staffed just like a road ambulance . . .
. . . is just an expensive noisy ambulance.
“Use of an ambulance-based helicopter retrieval service”
Wills VL, et al (2000) Aust NZ J Surg 70: 506-10
Audit of 179 helicopter scene responses to trauma patients.
Only 18% had ISS≥15 (68%≤9)
25% of patients < 35km from hospital
36% of patients discharged in < 48 hrs
81% patients helicopter non beneficial
17% beneficial (but 29 %of these died)
1.7% assessed as potentially harmed
What about HEMS with ATLS?
Baxt WG & Moody P, 1983
Impact of a Rotorcraft Aeromedical Care Service on Trauma Mortality JAMA 249: 3047
Moylan J, et al , 1986.
Factors Improving Survival in Multisystem Trauma Patients. Ann Surg 207: 679
Oestern HG, 1985.
The German Model for the Rescue of Trauma Patients. Can J Surg 28: 486.
Baxt WG, et al, 1985
Hospital Based Rotorcraft Aero-medical Services & Trauma Mortality: A Multi Centre Study Ann Emerg Med 14: 859.
Baxt WG & Moody P, 1987
The Impact of Advanced Prehospital Care on the Mortality of Severly Brain Injured Patients. J Trauma 27: 365
Bartolacci R, Munford BJ et al, 1998
Air medical scene response to blunt trauma: effect on early survival Med J Aust 169: 612
Is it the vehicle or the clinical team?
Baxt WG & Moody P, 1987.
The Impact of A Physician in the Aeromedical Prehospital Team in Patients with Blunt Trauma. JAMA 257: 3246
Schmidt U, et al, 1992.
On Scene Helicopter Transport of Patients with Multiple Injuries - Comparison of a German & an American system. J Trauma 33: 548
Garner A, Rashford S, et al, 1999.
Addition of Physicians to Paramedic Helicopter Services Decreases Blunt Trauma Mortality. Aust NZ J Surg 69: 697.
All studies showed improved mortality with physician based team but not with control group
Garner et al - findings:
Medical team:
Z = +2.72; p<0.01
W = +9.48 (3.84-15.12)
Paramedical team
Z = -1.16; p=0.25, NS
W= -2.37 (-6.81-+2.07)
A HEMS program is only as
good as its clinical crew . . .
. . . and only as good as the destination hospital
“Aye, there’s the rub”
-Hamlet
Any patient sick enough to need a helicopter (other than purely for difficult access) is sick enough to go to a trauma centre.
This may mean bypassing the local hospital
This is only acceptable if the clinical team has the skill mix to perform equivalent stabilisation on scene/enroute.
Trauma Centres and HEMS:
Symbiosis
Like pizza & beer
Like pancakes & maple syrup
Trauma centre by definition responsible for extended area.
Therefore needs “outreach” capability
But “outliers” who urgently need the trauma centre are least able to tolerate prolonged transport without stabilisation
Trauma Centres and HEMS:
Highest clinical standard
“Because we can”
– attributed to early “Pipeline” surfer
Trauma centre: full clinical resources with a multidisciplinary team
– Not feasible to provide at every hospital
HEMS should also have fullest clinical resources possible & a multidisciplinary team.
– Not feasible to provide on every ambulance
“Primary” vs “Secondary response
Irrelevant in trauma!
Individual response may (?should!) be uncertain at time of dispatch
Same measures required
ANZCA/ACEM/JFICM standards for interhospital transport
Should also apply to scene response to the critically injured.
So how about some answers?
Stage 1: Performance targets
Trauma Services should lead, not follow
Decide on realistic targets for trauma patient management
Then determine whether and what standard of HEMS can help achieve this (versus alternatives)
Example
E.g. for neurotrauma:
Patients with GCS <9 should have airway secured and normocapnic controlled IPPV within 60 minutes of emergency call.
Group A: performed at scene by ambulance
Group B: transported to hospital in <55mins
Group C: the (unlucky) rest
Now factor in the impact of HEMS
Results
The “swoop & scoop” approach to entrapped patients can be a problem:
Stage 2: System design
Decide on requirement for HEMS
Establish services as part of regional trauma plan
Under regional trauma/critical care system control with centralised tasking
Funding: standing cost retainer plus operating charge
Multidisciplinary medical crew (2+)
– Ambulance/medical/+/-nursing
Stage 3: Tasking
Central dispatch
Early callout
– Mechanism/interrogated response
– Multicasualty/entrapment
Respond to scene
– with potential diversion to local hospital
Clinical advice
Backup plan & capability
Active safety culture
Every (helicopter) home should have one
“Can do”
vs
“Can’t do”
“To a man who has a hammer,
every problem looks like a nail”
- Anon
SUMMARY
Trauma systems based on trauma centres need trauma outreach
Helicopter borne emergency medical services can help provide this
They are not the whole answer
Staffing and appropriate utilisation are paramount
The key is not more helicopters, but to make better use of less
The End
Questions, criticisms,
thoughts, comments?
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Ministry of Health
