Ambulance UK October 2023

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FEATURE Table 4 Available measures of interventions and monitoring stratified by age Data are given in n (%) All patients N = 68,333 Children (< N = 8,803 Adults (≥ N = 59,530 p N Measure available: 60,278 (88.2%) 7,923 (90.0%) 52,355 (87.9%) Basic interventions and monitoring iv access 49,923 (82.8%) 4,761 (60.1%) 45,162 (86.3%) SpO 2 51,214 (85.0%) 6,353 (80.2%) 44,861 (85.7%) ECG 30,974 (51.4%) 2,038 (25.7%) 28,936 (55.3%) Temperature 3,073 (5.10%) 421 (5.31%) 2,652 (5.07%) Immobilisation & analgesia Vacuum mattress 24,555 (40.7%) 4,041 (51.0%) 20,514 (39.2%) Sedation 613 (1.0%) 130 (1.6%) 483 (0.9%) Analgesia 31,928 (53.0%) 3,627 (45.8%) 28,301 (54.1%) Reduction of a fracture or dislocation 1,048 (1.7%) 124 (1.6%) 924 (1.8%) Haemostasis 1,460 (2.4%) 104 (1.3%) 1,356 (2.6%) Critical interventions i.o. access 548 (0.9%) 110 (1.4%) 438 (0.8%) eFONA 14 (0.02%) 1 (0.01%) 13 (0.02%) Chest needle decompression 182 (0.3%) 8 (0.1%) 174 (0.3%) transcutaneous paceing 139 (0.2%) 1 (0.01%) 138 (0.3%) Vasopressors 3,544 (5.9%) 202 (2.6%) 3342 (6.4%) Airway management Tracheal intubation 6,210 (10.3%) 421 (5.3%) 5,789 (11.1%) Facemask ventilation 2,822 (4.7%) 265 (3.3%) 2,557 (4.9%) NMBA 3,834 (6.4%) 251 (3.2%) 3,583 (6.8%) Capnography 6,884 (11.4%) 473 (6.0%) 6,411 (12.2%) Resuscitation Chest compressions 1,476 (2.5%) 104 (1.3%) 1,372 (2.6%) Defibrillation 8,68 (1.4%) 22 (0.3%) 846 (1.6%) Mechanical chest compression device 1,128 (1.9%) 26 (0.3%) 1,102 (2.1%) Other Other* 55,131 (91.5%) 6,727 (84.9%) 48,404 (92.5%) < 0.001 < 0.001 < 0.001 < 0.001 0.363 < 0.001 < 0.001 < 0.001 0.222 < 0.001 < 0.001 > 0.99 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 ECG electrocardiogram, eFONA emergency front of neck access, iv intravenous, i.o. intraosseous, NMBA neuromuscular blocking agent, SpO 2 peripheral oxygen saturation *Including but not limited to: wound dressing, vacuum splinting and cervical collar 68,333 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 60,278 AMBULANCE <strong>UK</strong> – OCTOBER outcomes [3]. Fixating solely on shortening on-scene times might not capture the reality for patients, as life-saving interventions performed at the prehospital stage substantially reduced mortality in trauma patients [7, 10]. Discovering the correct diagnosis may reduce the delivery time for definitive treatment. For example, stroke patients had improved functional outcomes when treated by a mobile prehospital stroke unit as compared to traditional treatment in hospital [22]. Helicopters enable missions to rescue patients, especially in remote and difficult terrain. Given the topography of Switzerland, with the Alps extending up to 4,634 m and many narrow valleys, these patients might be impossible to reach by ground ambulances. Many missions in this analysis involved patients undertaking recreational activities in the mountains in summer and winter (e.g. skiing, hiking or climbing). Rescue missions with ground-based evacuation teams could, to the patient’s disadvantage, easily require several hours just to reach the patient. A HEMS helicopter operating with a helicopter hoist can bring a physician to the patient directly and in a timely way, resulting in immediate access to clinical investigations and interventions [23]. This could be crucial, as an analysis of helicopter hoist missions in a physician-staffed HEMS reported that nearly 20% of the patients were severely injured and presented with a NACA score ≥ 4 [6]. Such helicopter hoist operations can avoid lengthy terrestrial evacuations, which potentially endanger both patients and rescue crews. Although our data revealed that helicopter hoist operations were associated with the greatest prolongation of on-scene time, the additional on-scene time spent in these HEMS missions results in substantially less rescue time and likely greater chances of neurologically intact survival, as compared to traditional ground rescue. Advanced airway management in a patient with respiratory failure or the need for a patent airway is a potentially life-saving intervention, which is performed safely by physician-staffed HEMS services, often anaesthesiologists [24]. This skill could even be performed in-cabin as an en-route treatment to optimise time management during the flight to the hospital [25]. Resuscitation was associated with prolonged on-scene time. Performing cardiopulmonary resuscitation in the cabin by HEMS is challenging due to the helicopter’s limited personnel resources and working space. Nonetheless, mechanical chest compression devices facilitate high-quality cardiopulmonary resuscitation in such situations [26]. No evidence, such as outcome data, is yet available for cases after the use of mechanical resuscitation 12 For further recruitment vacancies visit: www.ambulanceukonline.com
FEATURE Table 5 The regression coefficient of multivariable linear regression with the outcome on-scene time (in minutes) stratified by age Outcome: On-scene time (min) All patients Children (< Adults (16 ≥ years) Characteristic Beta 95% CI p Beta 95% CI p Beta 95% CI p Helicopter hoist operation (HHO) No – – – – – – Yes 15.1 14.7, 15.5 < 0.001 13.0 11.7, 14.3 < 0.001 15.1 14.6, 15.5 < 0.001 Critical interventions (per measure) 2.4 2.0, 2.9 < 0.001 2.7 1.5, 3.9 < 0.001 2.4 1.9, 2.9 < 0.001 Airway management (per measure) 2.4 2.3, 2.6 < 0.001 2.8 2.4, 3.2 < 0.001 2.4 2.2, 2.5 < 0.001 Resuscitation (per measure) 2.1 1.8, 2.5 < 0.001 1.6 0.03, 3.2 0.046 2.2 1.8, 2.5 < 0.001 Basic interventions and monitoring (per measure) Location *including but not limited to: wound dressing, vacuum splinting and cervical collar 1.9 1.7, 2.0 < 0.001 1.5 1.2, 1.8 < 0.001 2.0 1.8, 2.2 < 0.001 (per measure) 1.5 1.4, 1.7 < 0.001 1.1 0.72, 1.4 < 0.001 1.7 1.5, 1.8 < 0.001 Urban – – – – – – Remote 1.2 0.93, 1.5 < 0.001 − 0.35 − 0.90, 0.20 0.2 1.6 1.3, 1.9 < 0.001 Time of day Daytime (07:00–19:00) – – – – – – Night-time (otherwise) 1.0 0.65, 1.3 < 0.001 1.6 0.84, 2.4 < 0.001 0.86 0.49, 1.2 < 0.001 Other measures* (per measure) 0.82 0.75, 0.90 < 0.001 0.71 0.54, 0.87 < 0.001 0.85 0.77, 0.93 < 0.001 Non-trauma (per diagnosis) 0.67 0.49, 0.84 < 0.001 1.2 0.71, 1.8 < 0.001 0.68 0.49, 0.86 < 0.001 Trauma (per diagnosis) 0.41 0.28, 0.55 < 0.001 − 0.13 − 0.45, 0.20 0.4 0.47 0.32, 0.62 < 0.001 National Advisory Committee for Aeronautics (NACA) score NACA I–III – – – – – – NACA IV–VI 0.36 0.05, 0.67 0.021 0.43 − 0.13, 1.0 0.13 0.28 − 0.07, 0.62 0.12 Sex Female – – – – – – Male − 0.19 − 0.42, 0.05 0.12 − 0.39 − 0.85, 0.07 0.094 − 0.14 − 0.41, 0.12 0.3 Age category Children – – – – – – Adults − 0.83 − 1.2, − 0.49 < 0.001 Model performance Number of observations (N) 45,060 5,981 39,079 Adjusted R-squared 0.23 0.26 0.23 devices under HEMS conditions. Unfortunately, most of these devices cannot be used with paediatric patients, as reflected by the low numbers in our cohort. Critical interventions were regularly performed and associated with prolonged on-scene time. Most common in this cohort was the administration of intravenous vasopressors to maintain perfusion, intraosseous access and chest needle decompression. Intravenous access and analgesia were less frequently reported in children than in adults, even though children had more trauma. Our findings are in line with a recent observational study in a physicianstaffed HEMS [27]. Even if missions involving children were rare and physicians might not be that thoroughly trained in paediatric rescue, not to mention afraid of the potential risks, the reasons behind this inequity are unclear and require further investigation. Furthermore, the adjusted model revealed a slightly longer on-scene time for paediatric patients, while unadjusted on-scene time was shorter. This might be explained by statistical confounding, as paediatric patients had lower NACA scores compared to adults. However, while this finding was statistically significant, the clinical importance of a prolonged on-scene time of only 1 min might be negligible. Modifiable variables, such as the duration of a single measure (e.g. a critical intervention), have a significantly larger impact on on-scene time than non-modifiable factors, such as age category, type and number of diagnoses, and NACA score. Thus, reducing the duration of a single measure (intervention or monitoring) in these categories or performing these measures in parallel or during the flight as in-cabin treatment may hold significant potential to reduce on-scene time. While the measurements in our model were considered statistically independent, several measurements affect each other in clinical practice: A patient with a cardiac arrest is likely to be treated at least with chest compressions, defibrillation, intravenous or intraosseous access, vasopressors, intubation and capnography. Considering the time for all the single measurements, a cardiopulmonary resuscitation might easily last 10–15 min on-scene. For patients requiring emergency anaesthesia, baseline monitoring (SpO2, electrocardiogram, non-invasive blood pressure, and capnography), intravenous or intraosseous access, several medications (e.g. hypnotic, opioid, neuromuscular blocking agent, vasopressors), facemask AMBULANCE <strong>UK</strong> – OCTOBER For further recruitment vacancies visit: www.ambulanceukonline.com 13
Page 1 and 2: Volume 39 No. 5 October 2023 DEDICA
Page 3 and 4: CONTENTS CONTENTS Ambulance UK 4 ED
Page 5 and 6: EVE TR Ventilator INTENSIVE CARE/TR
Page 7 and 8: FEATURE FACTORS INFLUENCING ON-SCEN
Page 9 and 10: FEATURE Figure 1. Study flowchart D
Page 11: FEATURE Table 3 Diagnoses and on-sc
Page 15 and 16: FEATURE Figure 3. Effect plots of t
Page 17 and 18: FEATURE 11. Blasius FM, Horst K, Br
Page 19 and 20: Emergency Medical Technician Ron Dh
Page 21 and 22: NEWSLINE EEAST has so far enlisted
Page 23 and 24: NEWSLINE the events with other EEAS
Page 25 and 26: NEWSLINE mark the 25th anniversary.
Page 27 and 28: NEWSLINE identify as lonely and soc
Page 29 and 30: NEWSLINE no exception as we acknowl
Page 31 and 32: IN PERSON CEO of Essex & Herts Air

Ambulance UK October 2023

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