Air medical scene response to blunt trauma: effect on early survival

Abstract

Objective To assess the impact of on‐scene treatment by an experienced critical care physician on prehospital resuscitation, the initial hospital phase and early survival of patients with major blunt trauma. Design, setting and participants (i) Historical cohort of patients with trauma treated on scene by a helicopter emergency medical service (HEMS), 1986–1994, comparing medical and paramedical treatment and outcomes. (ii) Comparison of a subgroup of 77 patients (injury severity score [ISS] ≥ 15) treated by the air medical team (AMT) with (a) an ISS‐matched group of 308 patients treated by ground paramedics (GPMs) and (b) the Major Trauma Outcome Study cohort. Main outcome measures Procedural requirements assessed by the Therapeutic Intervention Scoring System (TISS), comparing resuscitation by medical and ambulance personnel; and observed versus expected mortality. Results (i) Of 445 patients treated on scene, 270 (61%) had sustained trauma, and 215 of these received early management by the AMT. Problems with ventilation or with volume resuscitation were encountered by general duties ambulance personnel (40%) and paramedics (60%) before arrival of the AMT. (ii) Matched patients treated by GPMs required significantly more emergency department interventions on arrival at hospital (P<0.01), and were possibly more likely to die in the first 48 hours (relative risk of death, 1.43; 95% confidence interval, 0.74–2.78) than patients treated by the AMT. Comparing the AMT‐treated patients with the Major Trauma Outcome Study cohort, 9 deaths occurred of the 18 that were predicted — a 50% reduction in predicted deaths (Z=3.38; P<0.001) — and there were 11 unexpected survivors and one unexpected death. The adjusted “W” statistic was 12.18 (ie, there were 12 more survivors per 100 patients than the Major Trauma Outcome Study prediction, after adjustment for casemix. Conclusions As part of the air medical team for response to major blunt trauma, a physician can provide significantly improved prehospital stabilisation, especially in airway and ventilatory control. Our results suggest improvement in mortality in AMT‐treated patients, probably due to the enhanced procedural capabilities of physicians, despite longer prehospital times.

Aeromedical Retrieval for Critical Clinical Conditions: 12 Years of Experience with the Royal Flying Doctor Service, Queensland, Australia

“…This is in line with the published literature, which suggests that providing an inexperienced doctor in the retrieval environment seems to provide no benefit, whereas the presence of a physician who can significantly improve pre-hospital stabilization will result in better outcomes even if the prehospital time is extended (30,31). In particular, RFDS doctors are able to provide advanced airway skills and the ability to independently perform rapid sequence induction and intubation, skills considered mandatory by some authors for the conduct of safe aeromedical retrieval (1).…”

“…In particular, RFDS doctors are able to provide advanced airway skills and the ability to independently perform rapid sequence induction and intubation, skills considered mandatory by some authors for the conduct of safe aeromedical retrieval (1). This is particularly important in the context of the extreme distances and prolonged travel times to definitive care, especially in the context where longer prehospital times can lead to improved outcomes if the time is spent by an experienced physician in preference to a paramedic stabilizing the patient (31,32).…”

Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence

“…Of those studies included, 19 29 34–51 compared HEMS with a ground medical transport (GMT), with 17 of these comparing the two transport modes delivering patients to the same hospital 29 34 35 37–39 42 44 46 47 51 or within an established trauma system 40 41 45 48–50. The remaining four30–33 compared HEMS with data from the national Major Trauma Outcome Study (MTOS).…”

The Impact of Aeromedical Response to Patients With Moderate to Severe Traumatic Brain Injury

“…Multiple other investigators have since performed similar descriptive or pseudoexperimental studies, often using TRISS calculations with or without comparison to a ground cohort, most of which support the efficacy of aeromedical response to major trauma victims. [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][34][35][36][37][39][40][41][42][43][44][45]47,[49][50][51][52] Biewener et al 48 performed a small cohort analysis comparing patients transported to a Level I trauma center by air to those transported to a Level II or III trauma center by ground. Improved outcomes were observed with immediate transport to a Level I trauma center by helicopter.…”