Physician utilization in prehospital emergency medical services in Europe: an overview and comparison. / Visión general y comparación de la presencia de médicos en los servicios de emergencias médicas prehospitalarios en Europa.

OBJECTIVES: National and regional systems for emergency medical care provision may differ greatly. We sought to determine whether or not physicians are utilized in prehospital care and to what extent they are present in differentEuropean countries. MATERIAL AND METHODS: We collected information on 32 European countries by reviewing publications and sending questionnaires to authors of relevant articles as well as to officials of ministries of health (or equivalent), representatives of national societies in emergency medicine, or well-known experts in the specialty. RESULTS: Thirty of the 32 of European countries we studied (94%) employ physicians in prehospital emergency medical services. In 17 of the 32 (53%), general practitioners also participate in prehospital emergency care. Emergency system models were described as Franco-German in 27 countries (84%), as hybrid in 17 (53%), and as Anglo-American in 14 (44%). Multiple models were present simultaneously in 17 countries (53%). We were able to differentiate between national prehospital emergency systems with a novel classification based on tiers reflecting the degree of physician utilization in the countries. We also grouped the national systems by average population and area served. CONCLUSION: There are notable differences in system designs and intensity of physician utilization between different geographic areas, countries, and regions in Europe. Several archetypal models (Franco-German, hybrid, and Anglo- American) exist simultaneously across Europe.

OBJETIVO: Los sistemas nacionales y regionales de prestación de atención médica a las emergencias pueden diferir mucho entre sí. Se buscó dilucidar la presencia de médicos en la atención prehospitalaria y su implantación en los diferentes países europeos. METODO: Se analizaron los datos de 32 países europeos recogidos mediante la revisión de artículos publicados y a través de cuestionarios enviados a los autores de artículos científicos pertinentes, funcionarios del ministerio de sanidad (o equivalente), representantes de sociedades nacionales de medicina de urgencias o expertos reconocidos en medicina de urgencias. RESULTADOS: Treinta de los 32 países europeos investigados (94%) disponen de médicos en los servicios de emergencias prehospitalarios. En 17 de 32 (53%), los médicos generalistas también participan en la atención a las emergencias prehospitalarias. Los modelos de los sistemas de emergencias médicas (SEM) se describieron como francoalemanes en 27 países (84%), híbridos en 17 (53%) o angloamericanos en 14 (44%). En 17 países (53%), coexistían diferentes modelos. Utilizando una nueva forma de clasificación por niveles, basada en la población media y el área atendida por el SEM prehospitalario, se pudieron diferenciar claramente los diferentes modelos existentes. CONCLUSIONES: Se observan notables diferencias en los diseños de los SEM y en la presencia de los médicos entre las diferentes áreas geográficas, países y regiones de Europa. Coexisten varios modelos (francoalemán, híbrido y angloamericano), algunos simultáneamente, en los diferentes países.

Visión general y comparación de la presencia de médicos en los servicios de emergencias médicas prehospitalarios en Europa / Physician utilization in prehospital emergency medical services in Europe: an overview and comparison

Antecedentes: Los sistemas nacionales y regionales de prestación de atención médica a las emergencias pueden diferir mucho entre sí. Se buscó dilucidar la presencia de médicos en la atención prehospitalaria y su implantación en los diferentes países europeos. Métodos: Se analizaron los datos de 32 países europeos recogidos mediante la revisión de artículos publicados y a través de cuestionarios enviados a los autores de artículos científicos pertinentes, funcionarios del ministerio de sanidad (o equivalente), representantes de sociedades nacionales de medicina de urgencias o expertos reconocidos en medicina de urgencias. Resultados: Treinta de los 32 países europeos investigados (94%) disponen de médicos en los servicios de emergencias prehospitalarios. En 17 de 32 (53%), los médicos generalistas también participan en la atención a las emergencias prehospitalarias. Los modelos de los sistemas de emergencias médicas (SEM) se describieron como francoalemanes en 27 países (84%), híbridos en 17 (53%) o angloamericanos en 14 (44%). En 17 países (53%), coexistían diferentes modelos. Utilizando una nueva forma de clasificación por niveles, basada en la población media y el área atendida por el SEM prehospitalario, se pudieron diferenciar claramente los diferentes modelos existentes. Conclusiones: Se observan notables diferencias en los diseños de los SEM y en la presencia de los médicos entre las diferentes áreas geográficas, países y regiones de Europa. Coexisten varios modelos (francoalemán, híbrido y angloamericano), algunos simultáneamente, en los diferentes países. (AU)

Background: National and regional systems for emergency medical care provision may differ greatly. We sought to determine whether or not physicians are utilized in prehospital care and to what extent they are present in different European countries. Methods: We collected information on 32 European countries by reviewing publications and sending questionnairesto authors of relevant articles as well as to officials of ministries of health (or equivalent), representatives of national societies in emergency medicine, or well-known experts in the specialty. Results: Thirty of the 32 of European countries we studied (94%) employ physicians in prehospital emergency medical services. In 17 of the 32 (53%), general practitioners also participate in prehospital emergency care. Emergency system models were described as Franco-German in 27 countries (84%), as hybrid in 17 (53%), and as Anglo-American in 14(44%). Multiple models were present simultaneously in 17 countries (53%). We were able to differentiate between national prehospital emergency systems with a novel classification based on tiers reflecting the degree of physician utilization in the countries. We also grouped the national systems by average population and area served. Conclusions: There are notable differences in system designs and intensity of physician utilization between different geographic areas, countries, and regions in Europe. Several archetypal models (Franco-German, hybrid, and AngloAmerican) exist simultaneously across Europe. (AU)

Output feedback based adaptive composite nonlinear flight control design for a small-scale un-crewed helicopter.

This correspondence deals with the trajectory tracking control of an un-crewed helicopter during hover/low-speed flights. A multi-loop architecture is used in which the inner-loop holds the fast changing dynamics and the outer-loop establishes the trajectory tracking. The inner-loop is closed with a constrained H∞ based controller which is cautiously designed to address actuator saturation, atmospheric wind disturbance, and parametric uncertainty. The outer-loop adaptive composite nonlinear control comprises of a linear part and a nonlinear part. A novel adaptive controller is proposed as the nonlinear part which improves the tracking performance by adaptively adjusting the damping ratio. The linear control element of the outer-loop is framed similar to inner-loop. Utilization of output feedback instead of full state feedback makes the flight control design simple and practically feasible. The closed loop stability and robustness property of the proposed scheme are analyzed. Simulation studies are performed to establish the hovering, station keeping, and trajectory tracking performance of the suggested control structure. Further, the performance of the proposed scheme is compared with a constrained static output feedback controller and a model reference adaptive proportional integral controller to confirm its superiority.

Assessment of helicopter passengers' vibration discomfort: proposal for improvement of the ISO 2631-1 standard.

High levels of vibration exist in helicopters and manufacturers are seeking to quantify vibration discomfort. They use the ISO 2631-1 standard, proposed for all types of transport. This study aimed to verify the validity of this index in the specific case of helicopters. Perception tests were carried out in the laboratory. Volunteers assessed the discomfort of vibratory stimuli on test benches generating vertical and triaxial vibrations. Foot, seat, and backrest accelerations were measured for each participant according to each stimulus. The ISO 2631-1 comfort indices were then compared with the evaluations given by the participants. The results showed that the standard provided a good estimate of discomfort. However, it lacks precision in estimating the discomfort of stimuli which include amplitude modulations, as can happen in helicopters. A new discomfort index is proposed based on ISO 2631-1 and allows better prediction of subjective assessments. Practitioner Summary: An improved index based on ISO 2631-1 standard is proposed to estimate helicopter vibratory discomfort for seated passengers. It takes into account the amplitude modulations that can appear at low frequencies in helicopters. This modification allowed a significant improvement of the accuracy of ISO 2631-1 for such stimuli.

Factors affecting development of air ambulance base: A systematic review and thematic analysis.

Nowadays, air ambulances have been developed as part of advanced emergency medicine services with many countries employing these services for transferring patients in usual and emergency conditions. However, there are challenges concerning the optimal development of air ambulance base. The present research aimed to identify factors affecting the development of air ambulance bases to provide the opportunity of planning to improve the quality of emergency medical services. In this systematic literature review, the peer-reviewed papers in fiv electronic databases, including Medline through PubMed, Scopus, Web of Science, ScienceDirect, and ProQuest, as well as available gray literature, were searched and selected. Two combinations of groups were used as keywords: the Health Planning and development factor, air ambulance base. The focus was on the PRISMA checklist, with no time limitations until from 1990 to January 2020. Finally, through 5156 related citations, 20 articles were included. Descriptive and thematic content analyses were evaluated. The factors affecting the development of the air ambulance base were classified in fiv categories and 14 subcategories as follows: navigation criteria, process indications and standards, sociopolitical factors, and current situation of the area. There are few studies on factors affecting the development of air ambulance bases. It is necessary to apply multidimensional models to consider various factors for development. The development of high populated cities, events and ceremonies with a crowd of participants, and increase of human-made disasters are making these services increasingly indispensable.

The utility of physician-staffed helicopters for managing individuals who experience severe isolated head trauma.

Objective: The authors retrospectively investigated prognostic factors for severe isolated head trauma in patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) or ground ambulance using data from the Japan Trauma Data Bank (JTDB). Patients and Methods: This study was a retrospective analysis of data housed in the JTDB database. The study period was from January 2004 to May 2019. Subjects were divided into two groups according to the method of transportation: helicopter (i.e., HEMS), which included patients transported by a physician-staffed helicopter; and ambulance, which included patients transported by ground ambulance. Results: A total of 41,358 patients were enrolled in the study, including 2,029 in the helicopter group and 39,329 in the ambulance group. The ratio of males, median head Abbreviated Injury Scale and Injury Severity Scale (ISS) scores were significantly greater in the helicopter group than in the ambulance group, while the average age, median Glasgow Coma Scale, average Revised Trauma Score (RTS), and survival rate were significantly lower in the helicopter group than in the ambulance group. Of the variables that demonstrated statistical significance in the univariate analysis and classification of transportation and included in the multivariate analysis, the following were identified as significant predictors of survival outcomes: younger age, lower ISS, female sex, and greater RTS. HEMS was not a significant predictor of survival. Conclusion: The present study revealed no effect of HEMS transport on the outcomes of patients who experienced severe isolated head trauma compared with ground ambulance transportation. Further prospective studies, including an analysis of the operation time or distance traveled by the HEMS and the functional outcome(s) of patients with severe head injury transported by HEMS, are warranted.

[In-cabin rapid sequence induction : Experience from alpine air rescue on reduction of the prehospital time]. / "In cabin rapid sequence induction" : Erfahrung aus der alpinen Luftrettung zur Verkürzung der Prähospitalzeit.

The survival of the severely injured is dependent on the rapid and efficient prehospital treatment. Despite all efforts over the last decades and despite an improved network of rescue helicopters, the time delay between the accident event and admission to the trauma room could not be reduced. A certain proportion of the severely injured need induction of anesthesia even before arrival in hospital (typically as rapid sequence induction, RSI). Due to the medical and technical progress in video laryngoscopy as well as in the means of air rescue used in German-speaking countries, under certain conditions the possibility to carry out induction of anesthesia and airway management in the cabin of the rescue helicopter, i.e. during the transportation, seems to be a possible option to reduce the prehospital time. The aspects dealt with in this article are elementary for a safe execution. A procedure that has been tried and trusted for some time is presented as an example; however, the in-cabin RSI should only be carried out by pretrained teams using a clear standard operating procedure.

London heliport: Noise emissions and the effect on local residents.

INTRODUCTION: The noise emissions from the operation of heliports situated in cities can have significant adverse impacts on a large number of local residents. Despite its significance, the effect of noise from rotary aircraft operation in an urban setting has not been extensively studied. OBJECTIVE: This paper presents for the first time an objective and subjective investigation into the noise emissions from the London Heliport and the associated impact on local residents. METHOD: Long-term noise monitoring measurements were taken at four locations and a social survey was implemented involving over 1500 respondents. A new objective measurement methodology was designed and developed that allowed individual air movements from the Heliport to be acoustically identified. Subjective results were contrasted with relevant social surveys and to the objective results. Objective results were also compared to planning guidance, local operation conditions and national and international based noise assessment criteria. RESULTS: Excessive sound levels were found, both internally and externally, which can be attributed directly to the operation of the Heliport. The high participation rate obtained in the social survey confirmed that noise emissions from the heliport operation cause important/substantial adverse impact on quality or life and well-being of the majority of respondents. CONCLUSIONS: The level of annoyance reported by respondents appeared higher than the level of annoyance attributed to the noise measurements at monitoring sites. As a study first of its kind, it is expected that the findings will inform and influence future regulatory policy and consequently improve the well-being of many residents.

The utility of physician-staffed helicopters for managing individuals who experience severe isolated head trauma / Journal of Rural Medicine

Objective: The authors retrospectively investigated prognostic factors for severe isolated head trauma in patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) or ground ambulance using data from the Japan Trauma Data Bank (JTDB).Patients and Methods: This study was a retrospective analysis of data housed in the JTDB database. The study period was from January 2004 to May 2019. Subjects were divided into two groups according to the method of transportation: helicopter (i.e., HEMS), which included patients transported by a physician-staffed helicopter; and ambulance, which included patients transported by ground ambulance.Results: A total of 41,358 patients were enrolled in the study, including 2,029 in the helicopter group and 39,329 in the ambulance group. The ratio of males, median head Abbreviated Injury Scale and Injury Severity Scale (ISS) scores were significantly greater in the helicopter group than in the ambulance group, while the average age, median Glasgow Coma Scale, average Revised Trauma Score (RTS), and survival rate were significantly lower in the helicopter group than in the ambulance group. Of the variables that demonstrated statistical significance in the univariate analysis and classification of transportation and included in the multivariate analysis, the following were identified as significant predictors of survival outcomes: younger age, lower ISS, female sex, and greater RTS. HEMS was not a significant predictor of survival.Conclusion: The present study revealed no effect of HEMS transport on the outcomes of patients who experienced severe isolated head trauma compared with ground ambulance transportation. Further prospective studies, including an analysis of the operation time or distance traveled by the HEMS and the functional outcome(s) of patients with severe head injury transported by HEMS, are warranted.

Ventilation of intubated patients during HEMS hoisting operations.

In response to the review "Advanced airway management in hoist and longline operations in mountain HEMS - considerations in austere environments: a narrative review." by Pietsch et al. we refer to recently published original research describing manual versus automatic ventilation of intubated patients during helicopter hoisting operations.

Neural network disturbance observer-based distributed finite-time formation tracking control for multiple unmanned helicopters.

The distributed finite-time formation tracking control problem for multiple unmanned helicopters is investigated in this paper. The control object is to maintain the positions of follower helicopters in formation with external interferences. The helicopter model is divided into a second order outer-loop subsystem and a second order inner-loop subsystem based on multiple-time scale features. Using radial basis function neural network (RBFNN) technique, we first propose a novel finite-time multivariable neural network disturbance observer (FMNNDO) to estimate the external disturbance and model uncertainty, where the neural network (NN) approximation errors can be dynamically compensated by adaptive law. Next, based on FMNNDO, a distributed finite-time formation tracking controller and a finite-time attitude tracking controller are designed using the nonsingular fast terminal sliding mode (NFTSM) method. In order to estimate the second derivative of the virtual desired attitude signal, a novel finite-time sliding mode integral filter is designed. Finally, Lyapunov analysis and multiple-time scale principle ensure the realization of control goal in finite-time. The effectiveness of the proposed FMNNDO and controllers are then verified by numerical simulations.

Ventilatory choices for intubated patients during helicopter stretcher winching.

INTRODUCTION: The winching of intubated patients on a stretcher into a helicopter is a rare event. Intermittent positive pressure ventilation is mandatory, which can either be performed manually with a self-inflating bag, or automatically using a portable ventilator. Theoretically automatic ventilation would provide improved oxygenation, more stable arterial carbon dioxide levels and a reduced risk of airway disconnection. Furthermore, the stretcher attendant may better perform winching procedures with higher situational awareness, contributing to crew and patient safety. However ventilator failure, and the diagnosis and management of such, is of concern. OBJECTIVE: The aim of this study is to compare automatic against manual ventilation during intubated helicopter stretcher winching. METHOD: The trial had two phases. Initially a static winch on a hoist simulator was performed, followed by live winching into a helicopter. All stretcher attendants performed two winches with an intubated manikin. During one winch, the manikin was manually ventilated, and an automatic ventilator was used for the other. Airway pressures were measured. RESULTS: Automatic ventilation did not fail. Compared with automatic ventilation, manual ventilation displayed significant pauses, inconsistent rates and both high and low airway pressures. Automatic ventilation permitted better situational awareness and performance in winching manoeuvres. One airway disconnection occurred during manual ventilation. CONCLUSIONS: During helicopter winching, automatic ventilation is superior in providing controlled, consistent and reliable ventilation for intubated patients. The stretcher attendant is also able to provide more attention to the winching manoeuvres with subsequent safety gains. The risk of automatic ventilator failure is low.

Extending helicopter operations to meet future integrated transportation needs.

Helicopters have the potential to be an integral part of the future transport system. They offer a means of rapid transit in an overly populated transport environment. However, one of the biggest limitations on rotary wing flight is their inability to fly in degraded visual conditions in the critical phases of approach and landing. This paper presents a study that developed and evaluated a Head up Display (HUD) to assist rotary wing pilots by extending landing to degraded visual conditions. The HUD was developed with the assistance of the Cognitive Work Analysis method as an approach for analysing the cognitive work of landing the helicopter. The HUD was tested in a fixed based flight simulator with qualified helicopter pilots. A qualitative analysis to assess situation awareness and workload found that the HUD enabled safe landing in degraded conditions whilst simultaneously enhancing situation awareness and reducing workload. Continued development in this area has the potential to extend the operational capability of helicopters in the future.

Analysis of patients with decompression illness transported via physician-staffed emergency helicopters.

CONTEXT: There have been few reports investigating the effects of air transportation on patients with decompression illness (DCI). AIMS: To investigate the influence of air transportation on patients with DCI transported via physician-staffed emergency helicopters (HEMS: Emergency medical system of physician-staffed emergency helicopters). SETTINGS AND DESIGN: A retrospective medical chart review in a single hospital. MATERIALS AND METHODS: A medical chart review was retrospectively performed in all patients with DCI transported via HEMS between July 2009 and June 2013. The exclusion criteria included cardiopulmonary arrest on surfacing. STATISTICAL ANALYSIS USED: The paired Student's t-test. RESULTS: A total of 28 patients were treated as subjects. Male and middle-aged subjects were predominant. The number of patients who suddenly surfaced was 15/28. All patients underwent oxygen therapy during flight, and all but one patient received the administration of lactate Ringer fluid. The subjective symptoms of eight of 28 subjects improved after the flight. The range of all flights under 300 m above sea level. There were no significant differences between the values obtained before and after the flight for Glasgow coma scale, blood pressure, and heart rate. Concerning the SpO2, statistically significant improvements were noted after the flight (96.2 ± 0.9% versus 97.3 ± 0.7%). There were no relationships between an improvement in subjective symptoms and the SpO2. CONCLUSION: Improvements in the subjective symptoms and/or SpO2 of patients with DCI may be observed when the patient is transported via HEMS under flights less than 300 m in height with the administration of oxygen and fluids.

Using lithium ion batteries in the aeromedical environment: a calculated risk?

Lithium ion batteries are increasingly utilised within helicopter emergency medical services. Their favourable chemical profile confers many desirable properties: they are small, lightweight and provide a high specific capacity (energy to weight ratio) coupled with a slow self-discharge rate, ensuring a longer functional availability for vital equipment. They are frequently used in routine medical equipment including ventilators, monitors and intravenous pumps, and in aviation specific items, such as satellite and mobile phones, VHF radios and navigation systems.

Characteristics of Emergency Patients Transported by Helicopter on Jeju Island

PURPOSE: The study investigated the present state of helicopter patient transport system on Jeju Island with the aim of improving the helicopter emergency medical service system. METHODS: Electrical medical records of patients transported to Jeju National University Hospital by coast guard helicopter from March 2009 to November 2010 were retrospectively reviewed. The followings were analyzed in terms of patient demography, pre-hospital treatment and monitoring during transport, emergency severity index (ESI) score, outcomes and appropriateness of transportation. RESULTS: During the 19 months of the study, 35 patients were helicopter-transported. There were 18 illness patients (51%) and 17 trauma patients (49%). There were 11 ESI level I patients (31.4%) and 8 ESI level II patients (11.4%). Treatment and monitoring during transportation were rare. 15 patients (43%) were hospitalized and 10(28%) died. 16 (45.7%) patients were indicated to the helicopter transportation. CONCLUSION: The near-absence of treatment and monitoring during helicopter transportation is thought to be associated with the absence of firefighting helicopter and trained medical staff. Appropriate emergency patient transportation protocols are needed.

Analysis of Patients were Transported by 119 Helicopter from Mountain Accident Scenes in Seoul

PURPOSE: Geographic problems can make it difficult for rescue teams to access emergency patients in the mountains. We developed the aeromedical relief program in conjunction with fire department helicopter EMS teams. This study describes the clinical experience of patients transported from the mountains in this program. METHODS: We reviewed the employed protocols and the medical records of patients transported to our hospital from the mountains by the aeromedical transport system from June 2006 to June 2007. RESULTS: Thirty-one patients were transported by helicopter during the study period, most of them (84%) from Mt. Bukhan. The time interval from call for help to hospital arrival was 80+/-56 min, and rescue time alone was 30+/-24 min. Eleven patients (36%) were pronounced dead on arrival, and 11 patients were admitted for management. The number of trauma patients were 24 (77%), who had an average RTS score (excluding the 11 patients who expired before arrival) of 11.7+/-0.6. When the ground team and the aeromedical team were dispatched at the same time, the total transport time was 54.0+/-22.8 min, compared to 133.0 +/-75.7 min when the aeromedical team was dispatched only upon the request of the ground team, a large and statistically significant difference. CONCLUSION: This study suggests that the helicopter transport system can be successfully employed to achieve early access to patients in the mountains. To optimize the current program, cooperation between hospital and the regional helicopter EMS is required.