Air ambulance paramedics-a question.
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I am sure the casualties would far prefer to be treated in hospital instead of in a field.
HEMS in UK hopefully leave the prehistoric 'swoop and scoop' concept to SAR crews. Your comment 'stay and play' demonstrates (if any more are needed) your ignorance of the subject.
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The difference between air and land Paramedics will depend on the local air and land ambulance service. All UK Paramedics are bound by the guidelines in JRCALC but, these are only guidelines, if you follow them word for word and it all goes wrong then the Paramedic will be held responsible.
A lot of UK air ambulances carry a Doctor on board and the Paramedics employed by that air ambulance service will be expected to assist that Doctor with certain procedures, RSI and chest drains being two examples.
The huge difference with putting a patient on to a helicopter (135, 109E or Explorer) is that everything needs to be done BEFORE you load. There is no room on these aircraft to change the way a patient is packaged so you have to stay and play, if I took a patient into an A+E dep't who was not properly packaged and without all the relevant procedures done I could be struck off.
Remember though that the majority of guys on here are pilots, and although they have a huge amount of experience they are not medically trained, just as I am not a trained pilot.
A lot of UK air ambulances carry a Doctor on board and the Paramedics employed by that air ambulance service will be expected to assist that Doctor with certain procedures, RSI and chest drains being two examples.
The huge difference with putting a patient on to a helicopter (135, 109E or Explorer) is that everything needs to be done BEFORE you load. There is no room on these aircraft to change the way a patient is packaged so you have to stay and play, if I took a patient into an A+E dep't who was not properly packaged and without all the relevant procedures done I could be struck off.
Remember though that the majority of guys on here are pilots, and although they have a huge amount of experience they are not medically trained, just as I am not a trained pilot.
Thread Starter
902 thanks for the offer, I may well take you up on your offer. I've already gleaned a better insight, just from this forum.
A quick and dirty evaluation tells me that emergency docs are performing stuff (eg RSI and intubation) that paramedics aren't (for various reasons).
Does anyone have any idea if there are any studies that demonstrate a difference in outcomes depending on who is on board?
Thanks for the contributions, and realise this forum focuses on aviation issues, rather than medical issues. (Sometimes feel like I gain a better feel for a subject on here though).
I'll bogg off on Thursday, as I would have done the talk then
A quick and dirty evaluation tells me that emergency docs are performing stuff (eg RSI and intubation) that paramedics aren't (for various reasons).
Does anyone have any idea if there are any studies that demonstrate a difference in outcomes depending on who is on board?
Thanks for the contributions, and realise this forum focuses on aviation issues, rather than medical issues. (Sometimes feel like I gain a better feel for a subject on here though).
I'll bogg off on Thursday, as I would have done the talk then
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Gingernut: Whilst an aviation forum may not be the optimum place to glean medical opinion, there has certainly been a good spread of responses!
The debate over the 'golden hour', 'stay and play', 'scoop and run', etc. has still to find a definitive answer. As with much in life, it often depends on the exact situation/circumstances - a hypothermic survivor from a hillside or the sea probably needs to be in the nearest hospital as soon as possible to get re-warmed in the most timely manner; the head injured patient needs an RSI and transfer to a neruo-surgical centre. Delays on scene may or may not be justified.
Essentially it boils down to getting the correct resources to the correct patient who must be transferred to the correct hospital in the correct time frame. Thus, air ambulances play their role in either getting expert resources (paramedics or doctors) to the incident scene or over flying 'local resources' to transfer the patient to definitive care (i.e trauma centre). Morbidity and mortality is known to increase for every subsequent transfer a patient is subjected to after reaching the first place of medical care...
London (and other large metropolitan districts) provide specific challenges - e.g getting expert care on scene in a timely manner. Getting to definitive care may well be most effectively achieved by then utilising road transport - this does not negate the need or usefulness of an air ambulance but requires a different mind set. It is certainly less dramatic arriving at hospital by ambulance than a helicopter, but this doesn't mean the HEMS system has not played a part!
Careflight in Sydney have been undertaking a trial with head injured patients which (from my understanding) attempts to address the question of the role of physicians in pre-hospital care. I believe that whilst the teams are flown to scene, the subsequent transfer is often (but not exclusively) by road. More details on their website:
CareFlight - Head Injury Retrieval Trial (HIRT)
There are studies looking at this area but they generally recruit small numbers with an associated difficulty in reaching statistical significance - there was a recent thread which touched on this area with a link to some medical articles. Trying to 'match' trauma cases for research purposes is notoriously difficult, costly and thus limited.
If you want more details or specific answers to the questions you posted regarding protocols/advanced practice/etc. I suggest you PM me - after all, as has been pointed out, it is a helicopter forum!
Simon
The debate over the 'golden hour', 'stay and play', 'scoop and run', etc. has still to find a definitive answer. As with much in life, it often depends on the exact situation/circumstances - a hypothermic survivor from a hillside or the sea probably needs to be in the nearest hospital as soon as possible to get re-warmed in the most timely manner; the head injured patient needs an RSI and transfer to a neruo-surgical centre. Delays on scene may or may not be justified.
Essentially it boils down to getting the correct resources to the correct patient who must be transferred to the correct hospital in the correct time frame. Thus, air ambulances play their role in either getting expert resources (paramedics or doctors) to the incident scene or over flying 'local resources' to transfer the patient to definitive care (i.e trauma centre). Morbidity and mortality is known to increase for every subsequent transfer a patient is subjected to after reaching the first place of medical care...
London (and other large metropolitan districts) provide specific challenges - e.g getting expert care on scene in a timely manner. Getting to definitive care may well be most effectively achieved by then utilising road transport - this does not negate the need or usefulness of an air ambulance but requires a different mind set. It is certainly less dramatic arriving at hospital by ambulance than a helicopter, but this doesn't mean the HEMS system has not played a part!
Careflight in Sydney have been undertaking a trial with head injured patients which (from my understanding) attempts to address the question of the role of physicians in pre-hospital care. I believe that whilst the teams are flown to scene, the subsequent transfer is often (but not exclusively) by road. More details on their website:
CareFlight - Head Injury Retrieval Trial (HIRT)
Does anyone have any idea if there are any studies that demonstrate a difference in outcomes depending on who is on board?
If you want more details or specific answers to the questions you posted regarding protocols/advanced practice/etc. I suggest you PM me - after all, as has been pointed out, it is a helicopter forum!
Simon
Epiphany - helisdw's post seems to indicate that things are far from clear cut in HEMS/EMS and calling one organisation's protocol prehistoric is surely a clear indicator of lack of understanding of the complexities of the issues - petulance doesn't become you.
The consultant anaesthetists who frequently fly with us are quite clear that getting the patient to definitive care is paramount - maybe because our aircraft is large enough to permit continued work on the casualty and maybe because the situations we are usually called to mean the casualty is in a hazardous environment, but stay and play is very rare.
A new protocol for cardiac patients is quite clear that scoop and run is the way forward as the best treatment for the condition is only available in hospital.
The consultant anaesthetists who frequently fly with us are quite clear that getting the patient to definitive care is paramount - maybe because our aircraft is large enough to permit continued work on the casualty and maybe because the situations we are usually called to mean the casualty is in a hazardous environment, but stay and play is very rare.
A new protocol for cardiac patients is quite clear that scoop and run is the way forward as the best treatment for the condition is only available in hospital.
There you have it in a nutshell, Crab - your aircraft is suited to one kind of patient care, so that's where your area of knowledge is centred. Occasionally you fly with a consultant from a nearby hospital (who also flies with the local Air Ambo) - he has made his very valid opinions clear.
Other contributors here have explained why treatment on board their aircraft is less likely to achieve the optimum patient outcome, which is why pre-hospital-medicine specialists travel on those aircraft to help produce the best result for the patient. These specialists, especially on aircraft operating in the Home Counties where they are actually employed by the Air Ambulance Trust, are in contact with duty consultants who also provide weekly clinical governance; top-cover that your volunteer consultant does not have.
It has been explained to you in the past that a RSI'd, stabilised patient does not require a trauma team to meet the aircraft on arrival at hospital (your anaeshetists will be able to explain the advantages this confers). In fact, several things have been explained to you but you still cherry-pick the snippets which appear to match your viewpoint. It may simply be that you don't realise that comments like:
are the conversational equivalents of a hand-grenade. Or you may just enjoy muck-spreading for the sake of it. I can't be sure.
Other contributors here have explained why treatment on board their aircraft is less likely to achieve the optimum patient outcome, which is why pre-hospital-medicine specialists travel on those aircraft to help produce the best result for the patient. These specialists, especially on aircraft operating in the Home Counties where they are actually employed by the Air Ambulance Trust, are in contact with duty consultants who also provide weekly clinical governance; top-cover that your volunteer consultant does not have.
It has been explained to you in the past that a RSI'd, stabilised patient does not require a trauma team to meet the aircraft on arrival at hospital (your anaeshetists will be able to explain the advantages this confers). In fact, several things have been explained to you but you still cherry-pick the snippets which appear to match your viewpoint. It may simply be that you don't realise that comments like:
We then come back to the dilemma of 'stay and play' or 'scoop and run'.
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Oh no it doesn't!
Crab
Total B@ll@cks!
The main changes within the 2010 guidelines for resusitation (I've just read them, which I think is MORE than you've done!) are :- The withdrawal of Atropine treatment and, once resusitation is started, a full cycle of 20mins is required (CPR & drug therapy) before the Paramedics can recognise 'life extinct' (recognise because they can't certify death, only a Dr can). THAT'S only 1 of the reasons AA crews 'stay and play' (Oh man - that is SO 60's).
Others would include entrapment RTC's (bit difficult NOT to wait then!), difficult extrication from scene, physically getting some (large) patients out of their house etc. etc. the list is endless (well almost).
As already stated in this thread doing CPR in the back of a smaller (but much more modern and capable) helicopter is hard work! Paramedic crews agree that better to do the 20 mins on scene. If you get a result take the patient to hospital for definitive aftercare. If no result.......well!
If your consultants are saying such things perhaps it's no surprise that that hospital has such a dubious reputation. I wouldn't send my MP there, let alone someone I actually liked!
Gingernut...
Apologies for the above rant! But getting back to your original thread.
As already stated, there are national guidlines for what a Paramedic can and cannot do. Obviously these skills are less than a Doctors, so they can pay the Paramedics peanuts (IMHO). However, there are local agreements which allow AA Paramedics enhanced skills which fall outside the national guidelines. These skills are taught, monitored and audited by hospital doctors, usually consultants.
There is also a move towards a CCP degree (Critical Care Practictioner) for Paramedics. This would probably equate to an ICU Paramedic elsewhere, where these enhanced skills would come under their normal remit.
A point to remember is that ALL practicing Paramedics have to be registered with the HPA, as do Doctors and Nurses. If they lose their registration, or are not registered they cannot practice anywhere, and face legal action if they do.
I have the highest regard for Air Ambulance crews wherever they are for their skill, dedication and commitment, and whoever said "self loading freight".........
Great CRM point! MUST bring that one up at my next annual.
So in a nutshell.....If you're in a bad way, get an Air Ambulance to get you to the right hospital within the right timeframe.
If you want a lift to hospital, don't care where or when, phone ARCC Kinloss and ask for CrabAir!
A new protocol for cardiac patients is quite clear that scoop and run is the way forward as the best treatment for the condition is only available in hospital.
The main changes within the 2010 guidelines for resusitation (I've just read them, which I think is MORE than you've done!) are :- The withdrawal of Atropine treatment and, once resusitation is started, a full cycle of 20mins is required (CPR & drug therapy) before the Paramedics can recognise 'life extinct' (recognise because they can't certify death, only a Dr can). THAT'S only 1 of the reasons AA crews 'stay and play' (Oh man - that is SO 60's).
Others would include entrapment RTC's (bit difficult NOT to wait then!), difficult extrication from scene, physically getting some (large) patients out of their house etc. etc. the list is endless (well almost).
As already stated in this thread doing CPR in the back of a smaller (but much more modern and capable) helicopter is hard work! Paramedic crews agree that better to do the 20 mins on scene. If you get a result take the patient to hospital for definitive aftercare. If no result.......well!
If your consultants are saying such things perhaps it's no surprise that that hospital has such a dubious reputation. I wouldn't send my MP there, let alone someone I actually liked!
Gingernut...
Apologies for the above rant! But getting back to your original thread.
As already stated, there are national guidlines for what a Paramedic can and cannot do. Obviously these skills are less than a Doctors, so they can pay the Paramedics peanuts (IMHO). However, there are local agreements which allow AA Paramedics enhanced skills which fall outside the national guidelines. These skills are taught, monitored and audited by hospital doctors, usually consultants.
There is also a move towards a CCP degree (Critical Care Practictioner) for Paramedics. This would probably equate to an ICU Paramedic elsewhere, where these enhanced skills would come under their normal remit.
A point to remember is that ALL practicing Paramedics have to be registered with the HPA, as do Doctors and Nurses. If they lose their registration, or are not registered they cannot practice anywhere, and face legal action if they do.
I have the highest regard for Air Ambulance crews wherever they are for their skill, dedication and commitment, and whoever said "self loading freight".........
Great CRM point! MUST bring that one up at my next annual.
So in a nutshell.....If you're in a bad way, get an Air Ambulance to get you to the right hospital within the right timeframe.
If you want a lift to hospital, don't care where or when, phone ARCC Kinloss and ask for CrabAir!
From my understanding the main role of a SAR aircraft in the UK is to take a person who is in a hostile area/situation to a place of safety. That place of safety can be considered the helicopter as that is normally a safer place than where they were (if a SAR aircraft is required). Thats not to say that the aircraft it is not used in other roles.
I know its allitle off topic but just to give the idea of why more often than not the SAR paramedics tend to package them for lift and treat them as best they can on the way to the hospital rather than "stay and play". ( a term i'v heard used by a few SAR paramedics and not just Crab).
I know its allitle off topic but just to give the idea of why more often than not the SAR paramedics tend to package them for lift and treat them as best they can on the way to the hospital rather than "stay and play". ( a term i'v heard used by a few SAR paramedics and not just Crab).
Lioncopter, good of you to try and act as interlocutor for us. However, Crab has form in this forum. You may not be aware that a lot of people in the HEMS/AA world used to do SAR for a living too (some in rather more senior positions to Crab). We also know which words, phrases or expressions 'flick people's switches' and are generally polite enough not to misuse them.
Ah then Bobby the ranter - I didn't say it was a JRCalc protocol or even a national one but maybe in your ivory tower you haven't heard of the National Infarct Angioplasty Project.
The aim is to get MI patients into a hospital with a cardiac catheter lab for angioplasty within 150 mins from the call for help. Our hospital of choice for this is Royal Devon and Exeter, bypassing NDDH if the patient meets the criteria.
Given the distance from said hospital that most of Devon is, a scoop and run is the probable weapon of choice.
so the tail is wagging the dog here - if the helicopter was bigger, you could do the 20 mins CPR on the way to hospital but you can't, so you don't and if the patient dies in a field.....well!!
As for the resus protocols, not only am I aware of them but have done them for real which I suspect you might not have - the advantage of a bigger helo with 2 pilots.
Thud - I think the medical standards in SAR aircraft have significantly risen since you and many other ex mil AA pilots did SAR.
Oh and while we are being so precious, exactly who goes out to do this stuff in the dark in UK?
The aim is to get MI patients into a hospital with a cardiac catheter lab for angioplasty within 150 mins from the call for help. Our hospital of choice for this is Royal Devon and Exeter, bypassing NDDH if the patient meets the criteria.
Given the distance from said hospital that most of Devon is, a scoop and run is the probable weapon of choice.
As already stated in this thread doing CPR in the back of a smaller (but much more modern and capable) helicopter is hard work! Paramedic crews agree that better to do the 20 mins on scene. If you get a result take the patient to hospital for definitive aftercare. If no result.......well!
As for the resus protocols, not only am I aware of them but have done them for real which I suspect you might not have - the advantage of a bigger helo with 2 pilots.
Thud - I think the medical standards in SAR aircraft have significantly risen since you and many other ex mil AA pilots did SAR.
Oh and while we are being so precious, exactly who goes out to do this stuff in the dark in UK?
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Just a quicky reply as I do not have time to read the whole thread...I beg forgiveness therefore if this has already been mentioned...but as for 'medical extended experience' think atmospheric pressure changes to the body due altitude changes during flight.
This, I understand, is a significant factor when considering all things anaesthesia and when dealing with internal bleeding, especially with head trauma.
A good sideline of enquiry, I suggest, is the care of 'patient accompanying' passengers:, ie: child patient accompanied by terrified but otherwise uninjured mother. Both need careful handling, but the latter is not sedated, is maybe in shock, is half scared out of her mind, has never been in a helicopter before, etc, etc. Now there's a challenge for the airborne EMS professional, especially when their hands are already full.
Dan
This, I understand, is a significant factor when considering all things anaesthesia and when dealing with internal bleeding, especially with head trauma.
A good sideline of enquiry, I suggest, is the care of 'patient accompanying' passengers:, ie: child patient accompanied by terrified but otherwise uninjured mother. Both need careful handling, but the latter is not sedated, is maybe in shock, is half scared out of her mind, has never been in a helicopter before, etc, etc. Now there's a challenge for the airborne EMS professional, especially when their hands are already full.
Dan
A good sideline of enquiry, I suggest, is the care of 'patient accompanying' passengers:, ie: child patient accompanied by terrified but otherwise uninjured mother. Both need careful handling, but the latter is not sedated, is maybe in shock, is half scared out of her mind, has never been in a helicopter before, etc, etc. Now there's a challenge for the airborne EMS professional, especially when their hands are already full.
Smallish helo (902) but we carry out CPR in flight and defibrillation if required. (also chest decompressions.) Most difficult piece of airborne ballet for the 2 paramedics seems to be dealing with a vomiting patient strapped to a spine board. (also gets quite slippery in the cabin)
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Crab, et al. - apologies if my previous post wasn't clear and has lent fuel to the fire...
In an attempt to clarify matters:
I have yet to see any published evidence that fully supports or fully refutes the concepts of 'the golden hour', 'scoop and run' or 'stay and play' to give them their colloquial titles. This does not mean that the evidence does not exist and is yet to be discovered, or that a Type II error (false negative) has not occurred in previous research.
Most would agree that it would seem self evident that some medical conditions mandate rapid transfer to a hospital and others require treatment at scene - there are an endless list of examples. However, as this has not been proven beyond reasonable doubt in any scientific literature I have seen, the conclusion reached is that the evidence base is lacking. You may use this lack of proof on either side of the debate, but ultimately it adds little to the weight of your argument.
On the whole, modern UK pre-hospital care is increasingly moving towards centralisation of trauma resources (and cardiac resources). Therefore patients are likely to face longer journeys to hospital - the earlier instigation of treatment(s) would theoretically seem to be beneficial. However, again, there is no concrete evidence as this is an emerging concept and as previously mentioned, a difficult field to do research in.
Ultimately within the UK, SAR and HEMS are very different - whether they should or shouldn't be is another debate. Perhaps in time this will change, but until my crystal ball comes back from maintenance, I'm afraid I shall have to remain in the dark... Based on Epiphany's last comment, at least I shall know who is accountable for the lack of illumination!
Simon
In an attempt to clarify matters:
I have yet to see any published evidence that fully supports or fully refutes the concepts of 'the golden hour', 'scoop and run' or 'stay and play' to give them their colloquial titles. This does not mean that the evidence does not exist and is yet to be discovered, or that a Type II error (false negative) has not occurred in previous research.
Most would agree that it would seem self evident that some medical conditions mandate rapid transfer to a hospital and others require treatment at scene - there are an endless list of examples. However, as this has not been proven beyond reasonable doubt in any scientific literature I have seen, the conclusion reached is that the evidence base is lacking. You may use this lack of proof on either side of the debate, but ultimately it adds little to the weight of your argument.
On the whole, modern UK pre-hospital care is increasingly moving towards centralisation of trauma resources (and cardiac resources). Therefore patients are likely to face longer journeys to hospital - the earlier instigation of treatment(s) would theoretically seem to be beneficial. However, again, there is no concrete evidence as this is an emerging concept and as previously mentioned, a difficult field to do research in.
Ultimately within the UK, SAR and HEMS are very different - whether they should or shouldn't be is another debate. Perhaps in time this will change, but until my crystal ball comes back from maintenance, I'm afraid I shall have to remain in the dark... Based on Epiphany's last comment, at least I shall know who is accountable for the lack of illumination!
Simon
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Crab how do you know if someone is having a STEMI and is suitable for PPCI? In my local area we take a full patient history and a 12 lead ECG, based on this we administer the appropriate drugs and transmit a 12 lead ECG to the receiving PPCI unit. The PPCI unit will then call back to tell us where to take the patient, this ensures that we get the right patient to the right place at the right time and is obviously not a load and go scenario.
20 min CPR on the way to hospital? Why are you taking dead people to hospital? The reason the 20 min asystole protocol exists is so we don't take dead patients to hospital. Do you have different protocols because you are not health care professionals?
20 min CPR on the way to hospital? Why are you taking dead people to hospital? The reason the 20 min asystole protocol exists is so we don't take dead patients to hospital. Do you have different protocols because you are not health care professionals?
