UK HEMS

[Rowan J]

Hi,

Am preparing a paper on current and future UK HEMS situation. Have read through lots of material including threads here - and am fascinated by the situation.

Don't want to offend anyone as you guys all do a great job. I'm not looking to dis the personal commitment and professionalism. Some of the questions I'm trying to address relate to how you might address the development of a national HEMS service:

How would you optimise aircraft utilisation?
How would you square costs and benefits?
How would you deal with the hours of darkness?
How would you distribute operating bases?
How would you integrate (if at all) with NHS and private healthcare?
Would you utilise capacity available on SAR and Police aircraft?
Would you perpetuate the current airframe (apparent) preferences?
Would you perpetuate the current crew configurations?

Appreciate that I'm not going to get these answers, just wanted to give flavour of the questions.

Why?

Because some say that the UK HEMS services are out of control with over-provision, under-utilisation, variable and unpredictable availability, inappropriate crew configuration and aircraft, disproportionate influence over the emergency medical system, misleading charity fundraising, lack of medical insight and direction, wide variation in cost base and no evidence of clinical benefit....or cost-effectiveness.

Are they right?

Rowan

[airmail]

Rowan

Firstly let me state that I'm a volunteer for one of the Air Ambulances so not a professional in any way but based on my (admittedly limited) knowledge of this world, I would suggest the following answers to your questions:

1. How would you optimise aircraft utilisation?
The simple answer at the moment is that it's a decision that is made by the 999 call centres or by professionals on the scene. On the basis of my real job (which I will not go into here) you cannot say that there will always be an accident that needs an AA at a certain place at a certain time so utilisation is always as and when.

2. How would you square costs and benefits?
You cannot based on the answer to question 1 and also my final point in this reply

3. How would you deal with the hours of darkness?
I can't answer this - needs a professional pilot to do so. However from my charity volunteer perspective it would need a lot more people to get involved to help raise money to be able to afford it.

4. How would you distribute operating bases?
At the moment it is done by county and it is down to them. Personally I think that local knowledge is best here.

5. How would you integrate (if at all) with NHS and private healthcare?
It is already intergrated with the NHS as detailed above, private healthcare doesn't tend to involve trauma victims so in the main it isn't applicable.

6. Would you utilise capacity available on SAR and Police aircraft?
Best left to the professionals to answer this one

7. Would you perpetuate the current airframe (apparent) preferences?
At the moment it is down to the charities that run the individual AA's. For reasons given below (that also relate to point 1), my personal belief is that it should stay that way.

8. Would you perpetuate the current crew configurations?
Not sure what you mean by this, I will let the professional pilots answer from their perspective but I think that I am right in saying that some AA's only carry Paramedics whilst some have Paramedics and Doctors on board.

In terms of your final paragraph, I would suggest that you read up on the Golden hour. Every time I do a talk or attend an event and talk about it I always have a dialogue with a Medical professional (which I am not) who agrees how important it is.

There is no (to my knowledge) control over the NHS in terms of tasking etc - it is down to them and as they dont have to pay for anything except the Paramedics wages, it could be argued that it is a cheap/get out of jail option for them. As everything but the Paramedics wages is paid for by the respective charities who respond when they are called out, I'm not sure how you can judge cost effectiveness.

Having read your post again, I'm of the opinion that you are probably a journalist given your inflamatory tones. If so, I've bitten but, as stated earlier, I'm just a volunteer albeit someone that knows a little bit about how AA's work and the constraints that they are under. Every single AA in the country does a great job with little or no government support and long may that continue.

[Bertie Thruster]

Hello again RJ.

development of a national HEMS service

Highly unlikely. Why:

How would you square costs and benefits? It's simply not possible.

no evidence of clinical benefit....or cost-effectiveness.

Correct.

UK HEMS are like cherries on the icing of a cake. Qualitative and not quantifiable. It's just that in the UK, people in most areas of the country want air ambulance helicopters...and so they pay for them.

Why do they pay? That is a really good question. There is huge support for the HEMS Charities in every area. They simply want the cherry on the cake and are prepared to diet, run 26 miles backwards, donate their pocket money for a month, pay a fine for every bunker shot, jump out of 'planes, walk to the North Pole, total body waxes (!), cycle thousands of miles, swim, run, eat; it is never ending and very inventive!

It is only an average cost of 50 pence a year from each adult, in any given area of the UK.

Originally I think the desire was driven by the historic legacy of Chuck and PT (and possibly MASH a little later), with more recent boosts from the Hampster and similar.

Most importantly safety wise the UK HEMS AOC holders are well regulated by the the CAA.

Leave it alone, its doing fine.


http://i70.photobucket.com/albums/i97/nmhsu/whirly.jpg
Thanks guys!

[Bugs to forty]

You're right Bertie. And while all those people want to raise money - they can have it. But that's hardly a sustainable business plan is it? It also dumbs down the need for road ambulances by changing their requirement and allowing the NHS to potentially offer a lesser service. And what about the RAF/RN/Coastguard? They're there for everyone if NEEDED, they dont cost a penny (other than the taxes we've already paid!) and are day/night all-weather capable.
Do all these people who donate their extra money understand that there's probably a proper Rescue helicopter only an hour away IF NEEDED?

[500e]

Ah yes Bugs to forty would that be the so called Golden hour.
The oversight may be poor but look at the alternative profit driven services in the US costly and not a particularly good safety record

[206 jock]

From a report published today by the National Audit Office:

"More patients should be immediately transferred to specialist trauma centres, it recommends, while many also do not receive the rehabilitative care when they leave hospital.
NAO recommends a network of specialised regional centres to improve care"

And if time to treat is vital (golden hour etc....) then helicopters are going to play an increasingly important role in appropriate trauma care. Getting seriously injured patients to the RIGHT place for their injuries is vital.

I was at a meeting yesterday where I heard that there are 4.4 serious trauma incidents in the London/Kent/Surrey/Sussex/Essex/Herts/East Anglia patch, per day. Shurley centralised treatment is surely a good idea? However, where exactly do you place the centre if time of treatment after accident is vital?

Bugs to forty, you are so out of touch with reality....does a coastguard helicopter routinely carry a trained A&E consultant to the scene of the accident?

[timex]

Most Police helicopters aren't equipped for trauma patients, the best we can do is a quicker transfer to a hospital with a Paramedic from the Ambulance service onboard. We carry basic first aid kits and a stretcher (although to carry a patient we have to re-role the A/C).

As to nights, the AA do not work at night although I know the combined Police/AA A/C in Wiltshire does.

The only way that the majority of Police can lift casevacs at Night is because we have a FLIR system and a Huge great bit floodlight to carry out an extensive recce before landing. NVG are not yet widespread.

[Spanish Waltzer]

Bugs to forty, you are so out of touch with reality....does a coastguard helicopter routinely carry a trained A&E consultant to the scene of the accident?

206 - I dont know you or your background but are you 'in touch with reality'?

With few notable exceptions AA do not carry trained A&E consultants either. They are exactly that A&E consultants. The vast majority of UK SAR helos carry a fully trained and qualified paramedic - just like an AA and just like a road ambulance. If you have ever had dealings with EMS/SAR you will realise that doctors are often way out of their comfort zone when in the back of a helo - they respect the great work of the paramedics who in turn respect the great work of the A&E staff once they get the patient there.

There is the right time & place for a road ambulance, an Air ambulance or a SAR helo. It is down to the dispatchers/controllers to decide the best unit for the job and they can only get that right 100% of the time if they receive 100% of the facts about the incident. How often do you think that happens?

SW

[206 jock]

SW, yes, well in touch thank you. I think your understanding of current AA practices is a little out of date.

The 'framework' document published last year left AA charities with little wiggle room. The charity with which I'm well acquainted have decided that it's necessary to make the extra investment in doctors, even though the NHS funding for paramedics does not cover A&E-trained doctors.

The point of trained air ambulance doctors is well understood: some charities (not the one I know well) toyed with take well-meaning but potentially overwhelmed local GP's for a joy ride and I agree with you: they were potentially more of a liability than an effecive patient benefit.

There is no doubt: air ambulances of any type of operation could not operate without fully-trained paramedics and their role must not be ignored, but as part of a doctor/paramedic team, their effectiveness is much greater. They
say so themselves.

And believe me, the number of operations that will have trained doctors on board will continue increase dramatically over the next few months and years - trustee liability will dictate that as much as patient care considerations. "Swoop and scoop" is soon to be replaced with "stay and play".....

[Bugs to forty]

206 Jock

"Swoop and scoop" is soon to be replaced with "stay and play".....

Dangerous sweeping statement I'd say.

[peterprobe]

Ah yet once again it falls into a pissing contest. A proper SAR aircraft vs Air Ambo. Jesus H priest, Air ambo do not take away the work that SAR do. They do not pretend to be SAR aircraft. If Mr and Mrs Tax payer would like to replace those Air Ambos with SAR aircraft every day of the week, God alone knows what the bill would be. If SAR can cover every accident/emergency that the Air Ambos do they would have to have a either a nuclear fuel tank or some star wars warp thing!!!. Air ambulances do not operate as specialist units apart from the road crews, Most but not all paramedics also work on the road as well as on the air side. Many call s are made from road Ambulances because they need help. They are perfectly capable of dealing with a situation but another pair or two of hands REALLY help the situation. I would love to see about another 18 odd Sea Kings or Merlins fitted for Air ambo around the country......... like that will happen. If the Air Ambo needs a winch or night capability they call SAR........... Bingo job done...... apparently they can always be there in an hour.......... yes Sarcastic because I have been there waiting for two hours because they were on another job!! So not taking piss out of their professional side. The truth is there is not enough of them.

[Bertie Thruster]

Merlot or cabernet sauvignon?

[peterprobe]

Red.... is all the same

[Spanish Waltzer]

206 - I bow to your expertise - although the AAs I have regular contact with (which tend to be in more remote/rural locations) do not at the moment operate routinely with Drs. Whether that is due to a cost factor or a charity/NHS decision I dont know but imagine its a waste of an asset keeping a trained A&E consultant sitting in an AA crewroom when he could be better employed at A&E.

I would be interested to learn a little more about this 'framework' document you refer. I guess its to do with liability? Although if so how does that tie in with the standard road ambulance crewing?

[Helinut]

Rowan,

Going back to your question (isn't thread creep wonderful), I am not sure it is the right set of questions, or at least, includes the important things.

You need to ask what you want your air ambulance to do. What is it for? Answering that question is a lot less about helicopters and a lot more about ill people, severe (and not so severe) trauma, the population density, the geography of the area the AA will serve and the disposition of hospitals and medical specialities within and without it. There are rather different deployment criteria for HEMS in different areas.

From that you are able to define a rationally based set of requirements for your helicopter operation. From that you can begin to decide a sensible aircraft and operating regime.

The London HEMS model (which is used in more and more places in the UK) is about getting a trauma team to the patient asap (i.e. within a few minutes). Subsequent patient transport is a secondary issue. The trauma team can (more or less) carry out lifesaving operations on the street. In places where there are lots of nasty accidents/deliberates, there are enough of these really serious incidents for such a service to be justified.

However, in a rural area, such a service is not going to work the same way at all. If you take an average rural county, the number of really serious incidents does not justify such a system. The trauma team would very rarely need to exercise their skills. If you make their area of coverage larger, they would often take too long to get to scene. So you need a different model: the rural HEMS. Here the emphasis is different. The purpose of HEMS here is rapid transport to a hopefully decent hospital. The medical team will often be paramedics or possibly a doc/paramedic, but they are not trained to the same level as the "trauma team" above. This is more the poop-scoop model. The justification here is the "golden hour" argument. Such units often get deployed to incidents as much for their remoteness and inaccessibility as the reported condition of the casualty/patient. This model is where the combined police/HEMS units live. The combined unit shares costs and shortens transit times, with a modest loss of specialist skills in the crew.

The third model in the UK is the Scottish system. I don't have firsthand experience but I understand it is mainly used to transport patients from outlying areas to the central major hospitals. This is less HEMS and more what the CAA call "air ambulance" which involves secondary transport of the patient. In Scotland, the patient is often transported in an aeroplane.

The fourth case is the CASEVAC carried out by non-HEMS police helicopters. It is not a major part of the police helicopter's role, but they are allowed to do a HEMSlike job, where the patient condition is life-threatening. Like the combined police/HEMS they can do night landings in rural areas because of the cameras/lights they carry, and most particularly because of the multi-crew operation and the very good local knowledge which is key. CASEVAC rates vary from never (in metropolitan areas) to pretty routine. CASEVAC rates at many police units have (understandably) dropped where HEMS has been introduced. However, some police units do quite a lot of night CASEVACs - others effectively very few. A paramedic from a land ambulance flies with the patient.

The organic way in which UK HEMS has developed is a response to demand (as well as other things).

Oh Yes. And none of this has anything to do with SAR..........

[Bugs to forty]

Oh Yes. And none of this has anything to do with SAR..........

.........as long as the weather's OK and it's not dark.

[Bertie Thruster]

Spanish;

I would be interested to learn a little more about this 'framework' document you refer

See: The Association of Air Ambulances in the UK (http://www.airambulanceassociation.co.uk/framework.php)

[GLGNDB]

The third model in the UK is the Scottish system. I don't have firsthand experience but I understand it is mainly used to transport patients from outlying areas to the central major hospitals. This is less HEMS and more what the CAA call "air ambulance" which involves secondary transport of the patient. In Scotland, the patient is often transported in an aeroplane.

I also believe that the Scottish Ambulance Service (part of NHS Scotland) provide funding for the service in Scotland - this consists of 2 EC-135's and 2 Beech 1900's.

It's also worth looking at the news section of HMS Gannet's website to see the number of Medevac cases that they deal with.

[Spanish Waltzer]

Thanks Bertie.

An interesting read. If this is the document to which 206 refers, then I dont read it the same way as him.

Whilst it suggests that a doctor-paramedic crew 'stastically' improves patient survival rates and perhaps in an ideal world it would be nice to have more drs onboard it also clearly states that the paramedic-paramedic model is used on 80% of AA and doesn't imply this must change.

Obviously in places like London having a dr within the crew makes sense but this framework document does not in my eyes leave 'little wiggle room' for other operators to have to follow suit. As with everything cost will be a major factor.

I accept 206, you have greater involvement with AA than me but are you referring more to urban based AA?

Regards - SW

[airmail]

SW, I think that 206 is involved with the same operation that I am (although I don't know that for sure). What I can say is that the one I raise money for has made the decision to have a qualified A+E doctor on board so that they can improve the service that they provide for their patients. It isn't a de facto requirement to have them just as it isn't a de facto requirement for a county to have an AA.

The bottom line is that AA's save lives that wouldn't be saved without them being available. People can talk about SAR & Coastguard cover but the nearest base to my county is about an hours flying time away which negates the whole point of the golden hour.

As I said in my first post on this thread, I'm only a volunteer, but in all the talks that I've done on behalf of my organisation, everyone is in favour of having one that is funded by charity.

[TorqueOfTheDevil]

They do not pretend to be SAR aircraft


If only that was the case. There are too many examples of a certain AA outfit doing exactly that...

[Bertie Thruster]

Wot...winching out at sea?

[[email protected]]

Or eating their own body-weight in chocolate watching skytv?:)