Aeromedical retrieval services characteristics globally: a scoping review.

BACKGROUND: Aeromedical emergency retrieval services play an important role in supporting patients with critical and often life-threatening clinical conditions. Aeromedical retrieval services help to provide fast access to definitive care for critically ill patients in under-served regions. Typically, fixed-wing aeromedical retrieval becomes the most viable transport option compared with rotary-wing aircraft when distances away from centres of definitive care extend beyond 200 kms. To our knowledge, there are no studies that have investigated fixed-wing aeromedical services in the member countries of the organisation for economic cooperation and development (OECD). A description of the global characteristics of aeromedical services will inform international collaboration to optimise clinical outcomes for patients. AIM: In this scoping review, we aimed to describe the features of government- and not-for-profit organisation-owned fixed-wing aeromedical retrieval services in some of the member countries of the OECD. METHODS: We followed scoping review methodology based on the grey literature search strategy identified in earlier studies. This mostly involved internet-based searches of the websites of fixed-wing aeromedical emergency retrieval services affiliated with the OECD member countries. RESULTS: We identified 460 potentially relevant records after searching Google Scholar (n = 24) and Google search engines (n = 436). After removing ineligible and duplicate information, this scoping review identified 86 government-and not-for-profit-operated fixed-wing aeromedical retrieval services as existing in 17 OECD countries. Concentrations of the services were greatest in the USA followed by Australia, Canada, and the UK. The most prevalent business models used across the identified OECD member countries comprised the government, not-for-profit, and hybrid models. Three-quarters of the not-for-profit and two-fifths of the hybrid business models were in the USA compared to other countries studied. The government or state-funded business model was most common in Australia (11/24, 46%), Canada (4/24, 17%), and the UK (4/24, 17%). The frequently used service delivery models adopted for patients of all ages included primary/secondary retrievals, secondary retrievals only, and service specialisation models. Of these service models, primary/secondary retrieval involving the transportation of adults and children from community clinics and primary health care facilities to centres of definitive care comprised the core tasks performed by most of the aeromedical retrieval services studied. The service specialisation model provided an extra layer of specialist health care dedicated to the transportation of neonates and paediatrics. At least eight aeromedical retrieval services catered solely for children from birth to 16 years of age. One aeromedical service, the royal flying doctor service in Australia also provided primary health care and telehealth services in addition to primary retrieval and interhospital transfer of patients. The doctor and registered nurse/paramedic (Franco-German model) and the nurse and/or paramedic (Anglo-American model) configurations were the most common staffing models used across the aeromedical services studied. CONCLUSIONS: The development and composition of fixed-wing aeromedical emergency retrieval services operated by not-for-profit organisations and governments in the OECD countries showed diversity in terms of governance arrangements, services provided, and staffing models used. We do not fully understand the impact of these differences on the quality of service provision, including equitable service access, highlighting a need for further research.

Prehospital Care: An International Comparison of Independently Developed Training Courses.

OBJECTIVE: Prehospital and retrieval medicine (PHRM) occurs in a complex work environment. Appropriate training is essential to ensure high standards of clinical care and logistic decision making. Before commencing the role, PHRM doctors have varying levels of experience. This narrative review article aims to describe and compare 6 internationally accepted PHRM courses. METHODS: Six PHRM course directors were asked to describe their course in terms of education methods used, course content, and assessment processes. Each of the directors contributed to the discussion process. RESULTS: Although developed independently, all 6 courses use a comparable combination of lectures, simulations, and discussion groups. The amount of each pedagogical modality varies between the courses. CONCLUSION: We have identified significant similarities and some important differences among some well-accepted independently developed PHRM courses worldwide. Differences in content and the methods of delivery appear linked to the background of participants and service case mix. The authors believe that even in the small niche of PHRM, courses need to be tailored to the participants and the "destination of the participants" (ie, where they are going to use their skills).

Combining in-situ simulation and live HEMS mission facilitator observation: a flexible learning concept.

BACKGROUND: Continuous medical education is essential in Helicopter Emergency Medical Services (HEMS). In-situ simulation training makes it possible to train in a familiar environment. The use of a dedicated facilitator is essential; however, when an in-situ simulation training session is interrupted by a live mission, the efforts invested in the training are left unfulfilled. This study aims to evaluate if HEMS mission observation and debriefing by the simulation facilitator is a feasible alternative to mission-interrupted simulation training, and how this alternative to simulation training is perceived by both facilitators and HEMS crew members. METHODS: Facilitator observation during live missions and post-mission debriefing was offered as an alternative to mission-interrupted simulation training over a one-year period at three HEMS bases. Immediate feedback was requested from crews and facilitators after each observed live mission on a predefined questionnaire. At the end of the study period, semi-structured interviews were performed with a sample of HEMS crew members and facilitators to further explore the experience with the concept. Numerical data about the sessions were recorded continuously. RESULTS: A total of 78 training sessions were attempted, with 46 (59%) of the simulations conducted as planned. Of the remaining, 23 (29%) were not started because the crew had other duties (fatigued crew or crew called for a mission where observation was inappropriate/impossible), and 9 (12%) training sessions were converted to observed live missions. In total, 43 (55%), 16 (21%) and 19 (24%) attempts to facilitate simulation training were undertaken on the three bases, respectively. The facilitators considered mission observation more challenging than simulation. The interviews identified local know-how, clinical skills, and excellent communication skills as important prerequisites for the facilitators to conduct live mission observation successfully. Participating crews and facilitators found simulation both valuable and needed. Being observed was initially perceived as unpleasant but later regarded as a helpful way of learning. CONCLUSION: Live mission observation and debriefing seems a feasible and well-received alternative to an in-situ simulation program in HEMS to maximise invested resources and maintain the learning outcome. Furthermore, additional training of simulation facilitators to handle the context of live mission observation may further improve the learning output.

Challenges to the implementation of in situ simulation at HEMS bases: a qualitative study of facilitators' expectations and strategies.

INTRODUCTION: Facilitators play an essential role in simulation-based training on helicopter emergency medical services (HEMS) bases. There is scant literature about the barriers to the implementation of simulation training in HEMS. The purpose of this explorative interview study was to identify factors that the local facilitators anticipated would challenge the smooth implementation of the program, and their strategies to overcome these before the national implementation of in situ simulation-based training locally, and subsequently, one year after the programme was initiated, to identify the actual challenges they had indeed experienced, and their solutions to overcome these. METHODS: A qualitative study with semi-structured group interviews of facilitators was undertaken before and after one year of simulation-based training on all HEMS bases and one Search and Rescue base. Systematic text condensation was used to extract facilitators' expectations and experiences. RESULTS: Facilitators identified 17 themes in the pre-study-year interviews. Pedagogical, motivational and logistical issues were amongst the dominant themes. Other key themes included management support, dedicated time for the facilitators and ongoing development of the facilitator. In the post-study-year interviews, the same themes were identified. Despite anxiety about the perceptions of, and enthusiasm for, simulation training amongst the HEMS crews, our facilitators describe increasing levels of motivation over the study period. CONCLUSION: Facilitators prognosticated the anticipated challenges to the successful implementation of simulation-based training on HEMS bases and suggested solutions for overcoming these challenges. After one year of simulation-based training, the facilitators reflected on the key factors for successful implementation.

National Implementation of In Situ Simulation-Based Training in Helicopter Emergency Medical Services: A Multicenter Study.

OBJECTIVE: Medical simulation is used in helicopter emergency services as a tool for training the crew. Using in situ simulation, we aimed to evaluate the degree of implementation, the barriers to completing simulation training, and the crew's attitude toward this form of training. METHODS: This was a 1-year prospective study on simulation at all 14 Norwegian helicopter emergency services bases and 1 search and rescue base. Local facilitators were educated and conducted simulations at their discretion. RESULTS: All bases agreed to participate initially, but 1 opted out because of technical difficulties. The number of simulations attempted at each base ranged from 1 to 46 (median = 17). Regardless of the base and the number of attempted simulations, participating crews scored self-evaluated satisfaction with this form of training highly. Having 2 local facilitators increased the number of attempted simulations, whereas facilitators' travel distance to work seemed to make no difference on the number of attempted simulations. CONCLUSION: Our study reveals considerable differences in the number of attempted simulations between bases despite being given the same prerequisites. The busiest bases completed fewer simulations than the rest of the bases. Our findings suggest that conditions related to the local facilitator are important for the successful implementation of simulation-based training in helicopter emergency services.

Live Tissue Training on Anesthetized Pigs for Air Ambulance Crews.

OBJECTIVE: Patients with life- or limb-threatening severe injuries pose a challenge to prehospital services. Time-critical decision making and treatment are challenging because of occasional incomplete information, limited resources, adverse environments, and a range of basic and advanced technical skills available. To prepare for these infrequent critical situations, medical personnel from the helicopter emergency medical service at Oslo University Hospital developed a 1-day advanced trauma training course focusing on individual skills and teamwork during resuscitative procedures. METHODS: Participants were trained under supervision in teams on an established live tissue model with anesthetized pigs. A questionnaire-based evaluation was conducted before and after training to measure the feasibility of covering the allocated learning objectives in the time allotted and participants' perception of any change in their skills as a result of the course. RESULTS: The self-reported skill level in all learning objectives improved significantly. Combining all learning objectives, the median self-reported skill level was significantly increased from 4 to 6 points (P < .001). CONCLUSION: Experienced prehospital physicians and other health staff reported an increased level of skill and competence in lifesaving and limb-saving procedures after completing a brief, intense 1-day course using living anesthetized pigs and cadaver models.

In situ simulation training in helicopter emergency medical services: feasible for on-call crews?

Simulation-based training of emergency teams offers a safe learning environment in which training in the management of the critically ill patient can be planned and practiced without harming the patient. We developed a concept for in situ simulation that can be carried out during on-call time. The aim of this study is to investigate the feasibility of introducing in situ, simulation-based training for the on-call team on a busy helicopter emergency medical service (HEMS) base. We carried out a one-year prospective study on simulation training during active duty at a busy Norwegian HEMS base, which has two helicopter crews on call 24/7. Training was conducted as low fidelity in situ simulation while the teams were on call. The training took place on or near the HEMS base. Eight scenarios were developed with learning objectives related to the mission profile of the base which includes primary missions for both medical and trauma patients of all ages, and interhospital transport of adults, children, and neonates. All scenarios included learning objectives for non-technical skills. A total of 44 simulations were carried out. Total median (quartiles) time consumption for on-call HEMS crew was 65 (59-73) min. Time for preparation of scenarios was 10 (5-11) min, time for simulations was 20 (19-26) min, cleaning up 7 (6-10) min, and debrief 35 (30-40) min. For all items on the questionnaire, the majority of respondents replied with the two most positive categories on the Likert scale. Our results demonstrate that in situ simulation training for on-call crews on a busy HEMS base is feasible with judicious investment of time and money. The participants were very positive about their experience and the impact of this type of training.

Decision support tool and suggestions for the development of guidelines for the helicopter transport of patients with COVID-19.

The novel coronavirus SARS-CoV2 emerged in December 2019 and is now pandemic. Initial analysis suggests that 5% of infected patients will require critical care, and that respiratory failure requiring intubation is associated with high mortality.Sick patients are geographically dispersed: most patients will remain in situ until they are in need of critical care. Additionally, there are likely to be patients who require retrieval for other reasons but who are co-incidentally infected with SARS-CoV-2 or shedding virus.The COVID-19 pandemic therefore poses a challenge to critical care retrieval systems, which often depend on small teams of specialists who live and work together closely. The infection or quarantining of a small absolute number of these staff could catastrophically compromise service delivery.Avoiding occupational exposure to COVID-19, and thereby ensuring service continuity, is the primary objective of aeromedical retrieval services during the pandemic. In this discussion paper we collaborated with helicopter emergency medical services(HEMS) worldwide to identify risks in retrieving COVID-19 patients, and develop strategies to mitigate these.Simulation involving the whole aeromedical retrieval team ensures that safety concerns can be addressed during the development of a standard operating procedure. Some services tested personal protective equipment and protocols in the aeromedical environment with simulation. We also incorporated experiences, standard operating procedures and approaches across several HEMS services internationally.As a result of this collaboration, we outline an approach to the safe aeromedical retrieval of a COVID-19 patient, and describe how this framework can be used to develop a local standard operating procedure.

The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region.

BACKGROUND: Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality. METHODS: Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality. RESULTS: Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality. CONCLUSIONS: Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.

Response to: Best practice advice on pre-hospital emergency anaesthesia & advanced airway management.

The European HEMS and Air ambulance Committee's Medical working group recently published Best Practice advice on pre-hospital emergency anaesthesia and advanced airway management. We believe that this initiative is important. In our opinion however, the competence requirements recommended by the authors do not meet the standards that we should aim for in HEMS services. We argue that pre-hospital emergency anaesthesia should be delivered with a competence level approximating in-hospital standard. In our experience, our patients benefit from pre-hospital emergency anaesthesia delivered by consultants with regular in-hospital rotations and a sound clinical governance system.

Inhaled nitric oxide might be a contributing tool for successful resuscitation of cardiac arrest related to pulmonary hypertension.

We describe a case where inhaled nitric oxide (iNO) was successfully initiated during cardiopulmonary resuscitation (CPR) in a younger patient with cardiac arrest related to pulmonary hypertension after disseminated intravascular coagulation (DIC) postpartum bleeding and hysterectomy. This case illustrates that iNO might be a potential lifesaving tool for resuscitation of patients with cardiac arrest related to pulmonary hypertension, for whom most other resuscitation strategies often are futile.

A prospective survey of critical care procedures performed by physicians in helicopter emergency medical service: is clinical exposure enough to stay proficient?

BACKGROUND: Physicians in prehospital care must be proficient in critical care procedures. Procedure proficiency requires a combination of training, experience and continuous clinical exposure. Most physicians in helicopter emergency medical service (HEMS) in Norway are well-trained and experienced anaesthesiologists, but we know little about their exposure to critical care procedures in the prehospital arena. This knowledge is required to plan clinical training and in-hospital practice to maintain core competences for a HEMS physician. METHODS: We collected survey data on critical care procedures performed by physicians at three HEMS bases in Norway for a one-year period. To correct for differences in duty time between physicians, the expected number of procedures performed in a full time engagement at each HEMS base was calculated. Data was analysed using descriptive statistics and expected procedure volume at each base was compared using one-way between group analysis of variance. RESULTS: We received data from 82.7 % of the duty hours in the study period. Physicians at Oslo University Hospital HEMS had the highest volume of procedures in most categories and were expected to perform a majority of the procedures at least once a year. There were significant differences in procedure volume between the bases in 25 procedures. CONCLUSIONS: Physicians in Norwegian HEMS perform critical care procedures with variable frequencies. The low procedure volume in some cases and variance between bases indicate the need for a tailored procedure maintenance training and relevant in-hospital clinical practice.

Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists.

BACKGROUND: A large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT). METHODS: Twenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint. RESULTS: During baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the post-training test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028). CONCLUSIONS: Testing the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.

Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model.

INTRODUCTION: We describe a system of scenario-based training using simple mannequins under realistic circumstances for the training of pre-hospital care providers. METHODS: A simple intubatable mannequin or student volunteers are used together with a training version of the equipment used on a routine basis by the pre-hospital care team (doctor + paramedic).Training is conducted outdoors at the base location all year round. The scenarios are led by scenario facilitators who are predominantly senior physicians. Their role is to brief the training team and guide the scenario, results of patient assessment and the simulated responses to interventions and treatment. Pilots, fire-fighters and medical students are utilised in scenarios to enhance realism by taking up roles as bystanders, additional ambulance staff and police. These scenario participants are briefed and introduced to the scene in a realistic manner. After completion of the scenario, the training team would usually be invited to prepare and deliver a hospital handover as they would in a real mission. A formal structured debrief then takes place. RESULTS: This training method technique has been used for the training of all London Helicopter Emergency Medical Service (London HEMS) doctors and paramedics over the last 24 months. Informal participant feedback suggests that this is a very useful teaching method, both for improving motor skills, critical decision-making, scene management and team interaction. Although formal assessment of this technique has not yet taken place we describe how this type of training is conducted in a busy operational pre-hospital trauma service. DISCUSSION: The teaching and maintenance of pre-hospital care skills is essential to an effective pre-hospital trauma care system. Simple mannequin based scenario training is feasible on a day-to-day basis and has the advantages of low cost, rapid set up and turn around. The scope of scenarios is limited only by the imagination of the trainers. Significant effort is made to put the participants into "the Zone"--the psychological mindset, where they believe they are in a realistic setting and treating a real patient, so that they gain the most from each teaching session. The method can be used for learning new skills, communication and leadership as well as maintaining existing skills. CONCLUSION: The method described is a low technology, low cost alternative to high technology simulation which may provide a useful adjunct to delivering effective training when properly prepared and delivered. We find this useful for both induction and regular training of pre-hospital trauma care providers.

Introduction and use of the ProSeal laryngeal mask airway as a rescue device in a pre-hospital trauma anaesthesia algorithm.

We report the successful use of the Proseal laryngeal mask airway as a rescue device in three pre-hospital cases where tracheal intubation after induction of anaesthesia had failed. The ProSeal LMA allowed ventilation and oxygenation of all three patients under difficult circumstances.