HEMS in an urbansetting Anne Weaver RESUS 2013, Limerick 27 th April 2013
Car at night
12 minutes by air 40 minutes by road 10 million people 25 mile radius
London HEMS Pan London service Operates as a charity Now known as London s Air Ambulance Mixed funding part state / part charity Charity funding - corporate / individuals
Why use a helicopter in an urban environment?
Average traffic speed: Normal traffic Emergency vehicles 9 mph 20 mph
Crew configuration 1 doctor 1 paramedic 1 training position Doctor Paramedic 2 pilots
Role of London s Air Ambulance Dedicated tomajor trauma patients Primary phase of incident 7 missions per day 4 day 3 night 365 days per year Physician Response Unit medical case mix Quality CPR, Autopulse, PCI protocol
Current workload 24/7 service 2000 trauma missions per year RTC 50% 50% pedestrian Falls 20% Penetrating Injury 25% Misc 5% Due to reach 30 000 missions by Nov 2013
Photo of thoractomy survivor and paper of accountant that was knifed 2005 - Stabbed after midnight died in the street
Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 Aug-06 Jul-06 Jun-06 May-06 Apr-06 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Adult Trauma Calls 130 2005 2006 2007 120 Major Incident 110 100 90 80 70 60 50 40 30 20 10 24 19 30 11 13 27 10 30 24 17 14 31 11 28 30 12 22 21 19 18 65 13 31 28 8 35 18 11 40 39 13 24 25 29 24 23 19 21 32 13 29 26 11 30 33 20 24 33 19 37 41 20 29 41 18 32 25 24 34 23 27 37 38 26 43 35 29 32 36 26 49 29 46 17 38 29 9 46 31 23 44 33 25 37 28 32 40 32 27 33 28 48 44 35 42 47 26 51 44 24 39 33 28 42 42 31 35 40 0 Day [08:00-17:00] Evening [17:00-24:00] Night [24:00-08:00] 1/3 rd were injured when service was not available Liz Foster 15/01/08; Data Source Anita West, Trauma Service Database
London HEMS milestones 1988 Commenced operations as Paramedic only Ad hoc requests eg organ pick up / transfers 1989 Medical team operations - physician & paramedic 1990 Commenced helipad operations at the Royal London First Rapid sequence induction 1991 First thoracotomy 2000 Evening car service 3 nights / week (midnight finish) Physician Response Unit 2010 London Trauma Network established, HEMS 24/7 2012 Blood on board
CODE RED Pre-alert from HEMS team Average age 34 yrs Mortality 49%
Major Incident response
Time to Definitive Care
Dispatch 4000 calls / day
Standard Operating Procedures Clinical & non-clinical Based on experience of service Encourages consistent practice Understanding tested in detail Aids decision making
Emergency Anaesthesia Kit Dump
Checklists Aircraft Rapid Response cars Medical packs Start & end of day routines Pre anaesthesia Challenge & response Reduce human factors effect
Catastrophic haemorrhage in PHC C ABC Tourniquets Novel haemostatic agents Handling and packaging Splintage Permissive hypotension Damage control resuscitation
Catastrophic haemorrhage@ London HEMS Utility of pre-alert protocols Massive haemorrhage protocols Pre-hospital transfusion Emergency reversal of warfarin Novel anticoagulants Aggressive vascular control in the field
CODE RED Developed and established at Royal London Now used by all SE England Air Ambulancesand the TaysideTrauma Team in Scotland
Pelvic injury
Early plasma
DECLARE CODE RED if: Systolic BP < 90 Poor response to initial fluid resuscitation Suspected active haemorrhage Non-evidence based criteria Activation based on PHYSIOLOGY NOT LABORATORY
CODE RED Massive Haemorrhage protocol Average age 34 yrs Mortality 49% Not good enough?
Blood on board March 2012
Golden Hour box 4 units O negative PRBC Data logger Paperwork
Belmont buddy lite Light weight Battery powered Temp sensor Extracts air from circuit Warms blood or saline Pressure limited 300mmHg
>1000 missions 50 prehospital transfusions 28 Code Red in extremis 22 traumatic cardiac arrests 11 PLE on scene 10 ROSC 1 infant in arrest to ED March September 2012 data
39 PH Txn to ED 24 survived 8 died in ED 3 died in OR 4 died on ICU March September 2012 data
Mean age 35yrs 80% male 45% ROSC from TCA March September 2012 data
2.8 units PRBC transfused On-scene time 37 mins Hb 14.0 ph 7.07 BE 12.8 March September 2012 data
Blood on board progress Over 100 pre-hospital transfusions Data collection for 50 transfusions Traumatic arrest improved ROSC (45%) Survivors have received blood and vascular control at scene iethoracotomy
What else can we do? Tranexamic acid Prothrombin Complex Concentrates
WARFARIN
Can pre-hospital teams make a difference? 999 14.54 LAS activation 14.56 On scene 15.00 Hospital 15.43 RSI 16.00 CT 16.15 INR result 16.45 Reversal 17.26 152 mins HEMS activation 15.01 HEMS on scene 15.10 HEMS RSI 15.25 HEMS INR 15.35 Reversal 15.45 HEMS at RLH 15.50 CT 16.00 51 mins
Prothrombin Complex Concentrates (Octaplex / Beriplex)
The future for bleeding patients? Freeze dried FFP / thawed FFP Fibrinogen concentrate Hand held ROTEM sophisticated pre-alert
Innovation for pre-hospital vascular control Thoracotomy for sub-diaphragmatic catastrophic bleeding (blunt and penetrating). To provide manual aortic occlusion and volume resuscitation with blood. REBOA resuscitative endovascular balloon occlusion of the aorta. Alternative way to occlude the aorta.
Urban pre-hospital care Aircraft essential for traversing congested areas rather than travelling long distances. Rapid response vehicles used for physician response unit, HEMS resilience and major incident response. Physicians offer the opportunity to deliver life-saving intervention close to time of injury. LAA have introduced interventions to reduce disability and death eg blood transfusion, PCC use. Developed expertise in penetrating trauma and major incident management.