Perceptions and culture of safety among helicopter emergency medical service personnel in the UK.

BACKGROUND: The use of helicopter emergency medical services (HEMS) has increased significantly in the UK since 1987. To date there has been no research that addresses HEMS pilots and medical crews' own ideas on the risks that they view as inherent in their line of work and how to mitigate these risks. The aim of this survey is to describe and compare the attitudes and perceptions towards risk in HEMS operations of these staff. METHODS: A questionnaire was administered electronically to a representative selection of HEMS doctors, paramedics and pilots in the UK. A number of questions were grouped into common themes, and presented as Likert scales and ranking where appropriate. Descriptive and comparative results were presented and statistically analysed. RESULTS: The target sample of 100 consecutive respondents was achieved. All questionnaires were entirely completed. Respondents attributed the most risk to night HEMS operations without the use of night vision goggles, commercial pressure and mechanical aircraft failure. There was no statistical difference in overall perception of safety and years of experience (p=0.58) or between professions (p=0.08). Those who had experienced a crash were more likely to believe that HEMS operations are not inherently safe (p=0.05). CONCLUSIONS: We have surveyed a cross-section of the HEMS operational community in the UK in order to describe their perceptions of safety and risk within their professional life. Two-thirds of respondents believed that HEMS operations were inherently safe. Those who did not seemed to be influenced by personal experience of a crash or serious incident. We support increased operational training for clinical crewmembers, an increased emphasis on incident reporting and a culture of safety, and careful attention to minimum training and equipment requirements for all HEMS missions.

Survival to Discharge After Cardiac Arrest Attended by a Doctor-Paramedic Helicopter Emergency Medical Service: An Utstein-style Multiservice Review of 1085 Activations.

BACKGROUND: The presentation of outcomes after cardiac arrest presented by emergency medical service and in-hospital teams in the Utstein style allows for comparative analysis of populations and systems. Essex and Herts Air Ambulance Trust (EHAAT) and the East Anglian Air Ambulance (EAAA) are doctor-plus-paramedic prehospital care teams that respond to a large number of medical cardiac arrests. OBJECTIVE: To report the outcomes of medical cardiac arrests according to the Utstein style. METHODS: Retrospective database analysis and hospital follow-up of all cardiac arrests attended by either service over a 31-month period. Traumatic cardiac arrests were excluded. PRIMARY OUTCOME: survival and cerebral performance category at discharge from the hospital. RESULTS: There were 429 patients attended by the two services; 193 patients achieved return of spontaneous circulation, which was sustained at the time of handover to the hospital team. Of 140 patients for whom complete follow-up was available, the overall survival rate was 50.7%, 86% of whom had a Cerebral Performance Category of 1 or 2. The overall survival-to-discharge rate for all patients attended was 11.7%. CONCLUSION: Benchmarking of performance is essential to understand reasons for variability, and to allow individual systems to reflect on their own practices. We have described 31 months of data that pertain to medical cardiac arrest cases attended by our services and demonstrated a comparable survival rate to discharge with good neurological outcome.

Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature.

OBJECTIVES: to determine the efficacy of the fascia iliaca block in providing analgesia to patients with a proximal femoral fracture in the emergency department. METHODS: EMBASE, PubMed, CINAHL and Google Scholar were searched. Free text keywords for population, intervention and outcome were identified to create a search string. The reference lists from articles identified in the primary electronic search were hand searched. Potentially eligible studies were identified based on review of the title and abstract. If eligibility was unclear from the title and abstract, the full text was examined. Randomised controlled trials comparing the fascia iliaca block with standard analgesia were included. A standardised appraisal of the methodological quality of the studies was performed. RESULTS: 39 articles were identified, of which 13 were duplicates. Of the remaining 26, 15 were relevant to the question and suitable for further sorting. There was one conference poster presenting data, which were later published as an audit, and so was considered to be a duplicate. Of the 14 remaining papers, 2 were randomised controlled trials, 6 were cohort studies and 3 were reports of audit of practice. There were 3 abstracts of conference poster or paper submissions, which were descriptions of reviews or service development projects rather than primary studies. The two randomised controlled trials showed statistically significant superior or equal pain relief between the fascia iliaca block and other forms of acute pain relief. CONCLUSIONS: the fascia iliaca block could have an important role in first-line pain control for patients presenting to the emergency department with a proximal femoral fracture. There is potential to reform the acute management of this common group of patients.

Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice.

INTRODUCTION: This paper describes the first 16-months experience of prehospital rapid sequence intubation (RSI) in a rural and suburban helicopter-based doctor-paramedic service after the introduction of a standard operating procedure (SOP) already proven in an urban trauma environment. METHOD: A retrospective database review of all missions between October 2010 and January 2012 was carried out. Any RSI or intubation carried out was included, regardless of age or indication. Patients who were intubated by Ambulance Service personnel prior to the arrival of the East Anglian Air Ambulance (EAAA) team were excluded. RESULTS: The team was activated 1156 times and attended 763 cases. A total of 88 RSIs occurring within the study period were identified as having been carried out by the EAAA team and meeting inclusion criteria for review. There were no failed intubations that required a rescue surgical airway or the placement of a supraglottic airway device. For road traffic collisions (RTCs), the overall on-scene time for patients who required an RSI was 40 min (range 15-72 min). For all other trauma, the average on-scene time was 48 min (range 25-77 min), and for medical patients, the average time spent at scene was 41 min (range 15-94 min). CONCLUSIONS: We have demonstrated the successful introduction of a prehospital care SOP, already tested in the urban trauma environment, to a rural and suburban air ambulance service operating a fulltime doctor-paramedic model. We have shown a zero failed intubation rate over 16 months of practice during which time over 750 missions were flown, with 11.5% of these resulting in an RSI.

The effect of the introduction of a regional major trauma network on triage decisions made by a physician-staffed helicopter emergency medical service.

BACKGROUND: A major trauma network (MTN) has been in place in the East of England, with a single hospital operating as the major trauma centre (MTC). The primary aim of this retrospective cohort study was to determine whether triage destination decisions with regard to trauma patients made by a helicopter-based doctor-paramedic team are affected by the introduction of a regional trauma network. In addition, we will describe and discuss the logistics of transfer of injured patients attended by the service. METHODS: This is a retrospective database review that was carried out over two 12-month periods. The first period was before the introduction of an MTN, and the second was after its introduction. All patients who were conveyed to an MTC were identified. Nontrauma patients were excluded. The MTN trauma triage tool was retrospectively applied. A comparative analysis of the two cohorts was carried out. For the group of patients conveyed to the regional MTC, additional follow-up information was obtained. This included patient survival at 30 days and the final injury severity score for each patient. RESULTS: A total of 220 cases were identified in which a major trauma patient was conveyed to an MTC. There were 94 cases in the year before the introduction of the MTN (cohort 1) and 124 in the year during which the MTN was active (cohort 2). There was no significant difference in the number of patients conveyed to each MTC between cohort 1 and cohort 2. The trauma triage tool status was 'positive' in 52.1% of cases in cohort 1 and 55.6% of cases in cohort 2 (P=0.60). Advice of the consultant on call was more commonly used for patients in cohort 2 than for those in cohort 1 (66.9 vs. 40.6%; P<0. 01). CONCLUSION: The introduction of a regional MTN has not significantly affected the triage decisions made by our physician-paramedic teams.

Ketamine for procedural sedation by a doctor-paramedic prehospital care team: a 4-year description of practice.

BACKGROUND: Ketamine is a widely used drug that, depending on the dose administered, may be used as an analgesic or as a sedative or anaesthetic agent. A number of features make it attractive for prehospital use. At Essex and Herts Air Ambulance Trust, as with other services and under the guidance of a standard operating procedure, ketamine is used for both procedural sedation and as an anaesthetic agent for rapid sequence intubation. Guidelines exist that define levels of sedation and detail minimum standards of monitoring and personnel required for each level. METHODS: We conducted a retrospective review from 4 years of our mission database for patients who had received ketamine for procedural sedation from the doctor-paramedic helicopter emergency medical service team. Other data relevant to the patient or the mission were also collected. RESULTS: A total of 212 cases of ketamine used for procedural sedation were identified. In all, 111 (52.4%) were for fracture manipulations and 52 (24.5%) were to facilitate extrication. An overall 12.7% of patients were paediatric (less than 18 years) and 160 (75.5%) were male. The helicopter emergency medical service team was with the patient for a mean of 24.4 min after the 999 call and spent a mean of 44.6 min on scene before departing for the hospital, which, in 75% of cases, was by means of a helicopter. A full set of monitoring was documented as having been used in 59 (27.8%) cases. CONCLUSION: We describe the use of ketamine over a 4-year period for prehospital procedural sedation. Minimum standards for patient monitoring were documented in only around a quarter of cases.

A 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents.

BACKGROUND: The use of helicopter emergency medical services (HEMS) has increased substantially in the United Kingdom since 1987. There are currently no data on the rate of crashes and serious incidents related to HEMS in the United Kingdom. The aims of this article were to present data from a 26-year period since the start of HEMS operations in the United Kingdom and to compare them with published data from Germany, Australia, and the United States. Factors identified as affecting the safety of HEMS operations will also be discussed. METHODS: A PubMed search was performed to retrieve published data on accident rates and safety discussions for international HEMS using the key words HEMS, helicopter, emergency medical services, accident, incident, and crash. The details of every helicopter crash in the United States since the beginning of HEMS operations was obtained and reviewed to identify those that involved HEMS aircraft. This novel UK information was compared with published data from three international systems. RESULTS: A total of 13 accidents or serious incidents involving HEMS aircraft were identified from Civil Aviation Authority records, only 1 of which was a fatal accident. It was estimated that approximately 230,000 HEMS missions occurred in the United Kingdom between 1987 and 2013, giving an absolute accident incidence of approximately 0.0057% and a fatal accident incidence of approximately 0.00043%. The accident and fatal accident rate per 10,000 missions in the United Kingdom was 0.57 and 0.04, respectively. This compares with published rates from Germany, Australia, and the United States with accident rate per 10,000 missions ranging between 0.57 and 0.75 and fatal accident rates per 10,000 missions ranging between 0.04 and 0.23. CONCLUSION: Accidents and serious incidents relating to HEMS operations in the United Kingdom have been comprehensively identified for the first time, allowing an estimation of overall accident and fatal accident rates and comparison with other countries' HEMS operations. Data collection and analysis were hampered by obscurity of data sources and poor availability of data. In a time of increasing HEMS use in the United Kingdom, it is essential to be mindful of safety, and standardization of data collection will improve focus in this important area.