Category Archives: conference bits

Reports from Warsaw – The Wrap from AirMed Part 2

OK it’s been a really long time. But it’s here. Dr Alan Garner returns with the wrap from AirMed Day 2, and it is absolutely not hot on the heels of the wrap from day 1. It’s good though. 

Unfortunately day 2 of Airmed was notable for a complete absence of Russian designed helicopters.  Fortunately there was enough of interest to keep me going.  Comments for day 2 have also been supplemented by notes taken by my colleagues Captain Greg Ohlsson and Dr Toby Fogg which helped me with the concurrency conundrum so thanks to both.


Day 2 kicked off bright and early with Klaus Egger from ÖAMTC in Austria with a Safety Analysis of current HEMS accident trends in Europe. He noted that accident databases are very poor and it was difficult for him to quantify exact numbers.  However he was able to deduce that the rate of accidents in Euro HEMS is static in real terms, though the fleet has increased by 25-30% so in terms of rate, it can be seen as a reducing trend.  This supports the notion of upgrading the fleet to modern IFR capable, glass cockpit twins.

Far and away the most common two accidents were wire strike and Controlled/Uncontrolled Flight into terrain or obstacles (CFIT).  There were a few other causes.  He railed against the intrusion of voice activated terrain and wire database warnings (EGPWS/HTAWS) pointing out that they are fitted everywhere and still had not changed the accident rate.  Indeed they provide significant distraction in the cockpit comms for HEMS crews.

He noted that in the CFIT incidents the collision was almost invariably with terrain that the crew already knew was there.  For example an aircraft brushed its main rotor tips against a rock wall during a winch.  The crew knew the cliff face was there but drifted just enough to strike it due to distraction.  HTAWS provides no additional situational awareness in that situation and actively distracts the crew – which seems to be the common thread in these incidents.

The technology is just not helping us here.  It was sobering to note the fatal crash of the Irish Coast Guard helicopter in the last 18 months involved the aircraft striking an island in poor visibility that was not in their mapping system.  You could argue in this case that reliance on the technology set up the crash.

Also notable was the fact that not a single accident was caused by engine failure. Huge amounts of money and regulatory effort have gone into mitigating this risk over the last 20 years.  It might be time to invest more in the risks that are actually killing crews. Having said that the accident rate is trending down – which shows that modern aircraft are a better safety proposition overall.

Next up was David Lockey from London HEMS on where are we heading in Prehospital Trauma Care.  I would describe this as the usual line up of suspects; REBOA, ECMO, POC testing, imaging etc.  To echo a point I have made on the Collective previously he concluded by asking whether we should do these things prehospital just because we can, as it seems we can do a lot.

Concurrent Activity

After morning tea the concurrent sessions kicked off.  I went off to hear Lionel Lamhaut describe the Paris experience with prehospital ECMO. The logistics of this are not inconsequential.  It takes a 6 person team; three to provide high quality CPR while ECMO is established and 3 to do the plumbing/EMCO bit.  7.5% of the time it fails for technical reasons.  He also noted that they have moved into REBOA as well and have done their first zone one case, which has since been reported in Resuscitation.

I then had to run to another session to watch our own Captain Greg Ohlsson speaking on our ten years of NVG experience in Australia.  Although some European operators such as REGA have been using the technology for much longer than we have CareFlight seems to have developed our own unique approach.

Greg outlined the three components of that; use of lots of white light as we approach the landing zone (we have installed additional lights all around our aircraft), a long slow approach, and what he terms “eye relief”.  In this last point he noted that unaided hovering cues are superior as depth perception works, good cues need less cognitive processing and we can light the unaided look around and produce good unaided hover cues (by point one – lots of white light).  Eye relief here means setting the goggles further away from the eyes so it is easier to look around them rather than through them.

The end result is that the crews look around the goggles more in the landing zone, depth perception is improved and less cognitive load is imposed on the crew.  I doubt I have explained this well but please contact us in the comments section below and we will put you in contact with Greg if you have any questions.

The Captain in action

Then it was another run between rooms to hear Herbert Schöchl from Austria on point of care testing, particularly around coagulation.  He noted that there were POC devices already on the market that can deliver an INR very rapidly but they were not very useful in trauma coagulopathy as it is clot strength rather than time to clot per se that is the issue.

He then described some testing they had been doing on the TEG 6S that will give a measure of clot strength in 2mins. He sort of implied that it is small and light enough for prehospital (or at least interfacility transport) use, though local types who have seen it in action tell me it’s still a bit of a beast.

They had been testing the effect of vibration on the measurement as they were worried this would produce unacceptable artefact or disrupt the reading, but this turned out not to be an issue.  You will understand why they were worried about this when you look at this picture – the device measures clot strength by measuring resonance frequency of the meniscus.  It at least looks like we’re getting closer to a more mobile TEG or ROTEM system.


Dispatched to Dispatch

After morning team it was off to a workshop (in my favourite venue behind the bar) on HEMS dispatch.

There were two speakers here that grabbed my interest.  The first was Kevin Hutton from the US who gave a very interesting perspective on appropriate utilisation from a cost perspective.  Large bills for HEMS transport have been making the news a lot in the US recently with charges to individual patients of up to USD50,000! The reason is the reimbursement system.  The HEMS companies cannot recover any funds from about 80% of the patients transported. So they have to recover the costs of these 80% from the other 20% and when you understand this the charges to the insured few start to make sense.  Just part of the madness of the system that is healthcare in the US.

The other presented was from the East of England Ambulance Service.  This was a system I had previously worked in and it has moved on a lot from when I was there eight years ago.  I thought their immediate dispatch criteria for HEMS were spot on.  They have been refining these for many years and Sydney could certainly learn from this.

Please enjoy this hastily grabbed slideshot.

Field Notes from Toby Fogg

While I was in the back of the bar my colleague Toby Fogg attended a session on medical competencies in HEMS – an area in which he has some interest.  Here are his notes, faithfully reproduced for the reader:

“Competencies in the HEMS World – by Akos Soti from Hungarian Air Ambulance.”

He carried out a survey of self-reported competency using this scale:

  1. Fully competent
  2. Competent – proper knowledge/training, not a routine intervention, would/can do if necessary
  3. Partly competent – some knowledge/information but not properly trained; would try as a last resort.
  4. Non-Competent – no/minor knowledge of the procedure; would not perform.


LPR service – 88% consultants, 84% male, 80% age 30-50. 61% anaesthetics, 28% ED – very different from ours in Sydney. Occasional neurologist or trauma surgeon.  Their self-reported competence is 1 or 2 on the above scale.

  • Surgical airway 93% felt competent, 68% have done one.
  • Chest decompression, 97% competent,
  • USS 79% for vascular access, 79% for chest, 63% for RUSH and FAST
  • Thoracotomy 40% , Resuscitative hysterotomy 30% competent and 7% had done one.
  • HUET 44% competent.

Then Matthais Ruppert from ADAC was up: They carry out 50,000 missions per year and are daytime only. Only 40-60% of patients are transported with 10% interhospital transfers.  Drs are on duty 2-4 days per month, much like Sydney and the service is mostly consultants so little turnover.  Training involves simulation e.g. inflight deterioration and conflict resolution in the interhospital setting.

Jens Stubager Knusden, an Intensivist from Denmark ACRM instructor presented on the Danish model.  Shift patterns: Doctors are on duty 3 days straight, pilot/ACM do one week straight, living on base as a team.  The pilots trained to be medical assistants.  There is a strong emphasis on Medical/Scenario Debriefing and then ACRM debriefing.

The final speaker was Andreas Kruger from Norwegian Air Ambulance.  His theme was that the right skills and right tools are required to deliver excellence. They have a highly efficient tasking system – the medical dispatchers are able to view the telemetry from the road ambulance in order to aid decisions.  He also talked of some of his research, looking at physiology mapping for the patient.

“The fact that many medical experts point to a variable, does not make it a good quality indicator – one needs to be able to get a meaningful and useable number. The variable must have values that have a clear ordering from not-so-good to very-good. It should have the potential for sufficient variation.”

He also discussed system wide performance mapping and quality indicators such as the airway registry for which he has published a series of Utstein-like Criteria.

Enough of the Field Notes

At the end of these concurrent sessions it was time for lunch.  This was the first time that I recall seeing my colleague Dr Chris Cheeseman. This was odd as the Polish doctors I last saw him with had all been there for the first session at 8am.

I unfortunately had to catch a train for Berlin so missed the final clinical session.  The news at the closing ceremony was that Airmed 2021 will be held in Salzburg.  The Sound of Music Airmed.  Can’t wait.




If you’re into quality indicators, you might like this paper:

Haugland H, Rehn M, Klepstad P, Krüger A. Developing quality indicators for physician- staffed emergency medical services: a consensus process. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2nd ed. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2017 Feb 14;25(1):1–8.

And would you like another chance to look at that paper reporting the first successful prehospital zone 1 REBOA? Then look here.


Reports from Warsaw – The AirMed Wrap Part 1

There are whole shows set up for glorified travel diaries. Why not have Dr Alan Garner do the same? Except with medical bits also, because that’s what the site is for. 

In October 2017 Airmed was due to take place in London. It all fell through though. Probably not because of Brexit. Maybe. There were arrangements with Helitech that fell through and … actually let’s forget that bit. The good news was that 400 delegates from 35 countries turned up to Warsaw on the 13th and 14th of June for a fresh running and a reminders that friends and colleagues all over deal with many of the same issues we do. A few different ones too mind you.

The Preamble

Why just turn up for the meeting though? We arranged a visit with the local air ambulance operator Lotnicze Pogotowie Ratunkowe the day prior. The local system has come a very long way in a relatively short time. It was only 7 years ago that they said goodbye to their last Mi-2. I am going to say I have a strange and irrational love of Russian designed helicopters so seeing this was a real highlight for me.

Here is Dr Toby Fogg displaying the sort of joy near the Mi-2 and it’s de-icing system you usually only see in stock photo models holding random fruit. Dr Thomasz Derkowski, gracious host and all round nice guy is on the far right.

They now have a fleet of >20 EC135s with Aerolite medical interiors, their own simulator to train their > 100 pilots as well as operating a couple of Piaggio fixed wings for longer distance transports. Times change.

Lots of room back here for medical care although I doubt the seating would pass modern crash worthiness standards.

One of their great challenges is coordination and tasking.The entire country is managed from the base we visited near Warsaw for interfaculty transports. Prehospital dispatch is done by one of 40 local dispatch centres around the country. There is a huge amount of variability in the prehospital dispatch accuracy however.

Pity about the accuracy because these new beasts are very impressive, particularly when not surrounded by this motley bunch.

We were told that to become a dispatcher you simply required 5 years prehospital experience as a paramedic. There is a dispatch course but it is not necessary to complete this until you have been doing the dispatch job for three years. That is a lot of time dispatching.

We were fortunate enough to have a presentation by one of their senior pilots where he described the weaknesses of the system. I quote directly from his slide to mention two of them:

  • “Strange, incomprehensible fears
  • Unjustified prohibitions of helicopter summon, issued by superiors”.

Sometimes when you start in another language and translate to English you get a slightly different take on an issue that turned out to be very familiar.

Big Strides

A very impressive part of what we saw turned out to be the strides they are taking to standardise their medical approach. This is being led by Tomasz Derkowski, their medical director. Tomasz has previously worked with LifeFlight in Queensland. It is quite a small world it turns out.

There has been a lot of work put into standardising their equipment across the country and introducing checklists for things like intubation. On the governance side there appears to be a much bigger issue as medical governance systems are not privileged by legislation in Poland.

Apparently there are moves to change this but I don’t think real advances can be made till this is in place as it is otherwise really hard to build an open culture.

They have recently (as in, this past week) introduced ultrasound to their system and have a lot of other new things planned but introducing things takes time when you have more than 20 bases to consider.

Day One Gets Going

After a brief bit of time with the Polish Minister for Health, Lukasz Szumowski, the clinical sessions kicked off.

The first of these commenced with the account of the rescue of a 30-year-old kayaker from a really cold lake in Sweden where the water temperature was 2.8 degrees.  The story was remarkable for the cross border and interagency cooperation required to effect his rescue and it was told by the three members of the Norwegian helicopter crew involved.

“Norwegians??” you might be thinking. Well the closest Swedish helicopter to the scene did not a have a rescue swimmer available so a Norwegian chopper was also dispatched with the information passing through rescue coordination centres in Sweden and then Norway.

The Swedish helicopter crew located the man in the water floating face down and directed the Norwegian team to effect the rescue by long line from where they lifted him to a small clearing in a forest.  The crewman showed amazing situational awareness having determined that the helicopter could not land due to the trees.  So he dragged the patient 10-20 metres along the ground to a more open area (still attached to the line) so that the helicopter could land.

The doctor then went to work with the crewman and pilot to resuscitate the patient.  He was asystolic with oesophageal temperature of 20 degrees Celsius.  A LUCAS device was applied and the patient was intubated.  In a great demonstration of the cross-skilling that occurs in these small integrated teams the pilot assisted the doctor in the intubation by performing external laryngeal manipulation.

By this time that Norwegian helicopter did not have enough fuel to transport the patient to the nearest ECMO centre which was back in Norway where it had originated from.  The patient was therefore driven by a Swedish ambulance 2 kms to the landing site of the Swedish helicopter where the patient was loaded with the Norwegian doctor and transported.  He subsequently made a full recovery, presumably to tell the tale of how impressive the team work within the helicopter team, between the helicopter teams and between the rescue coordination systems of two countries was. Once he is told the story.

There was a whole stream devoted to hypothermia in the afternoon which I did not attend, as this is a big issue for the Northern Europeans who seem to have very well developed systems for rewarming on EMCO.  This patient was certainly the ideal candidate as he was young and healthy and had cooled slowly whilst hanging on to the kayak before eventually losing consciousness.  The crew were aware of these circumstances and continued aggressive resuscitation over an extended period to get this result.

Then Wolfgang Voelckel from Vienna was up.  He spoke on professional networking and mentioned some new data from clinical trials he has conducted on prehospital fibrinogen.  More on this later.  The session closed with Erik Norman from Norway speaking on improved medical care through aviation.  The point that stuck was that aviation had made enormous gains in avionics and autopilot systems.  But the regulations are the same as they were 30 years ago in terms of visibility and minima. Perhaps it is time for a change given some aircraft now have autohover systems certified down to 3ft from the ground!

Second Servings

There were a couple of highlights here.  The first was a talk by Jostein Hagemo and Even Wøllo from Norway looking at the medical workspace that is a helicopter.  They have been keen to apply industrial design principles to improve medical care when airborne.  They noted that for the helicopter there is a master alarm when things go wrong.  In the back seat though there are multiple different pieces of equipment (ventilator, monitor, syringe drivers etc etc) each of which has its own alarms and nothing is integrated.  Perhaps the only way to solve this is to have single device that does everything the patient needs.  This seems unlikely for the moment.

They also did a bit of brainstorming about the stroke helicopter of the future…

CT Helo

Hmmm… well the word ‘brainstorm’ doesn’t tell you if it’s a good one, just that it happened.

We then heard from Jaap Hatenboer from the Netherlands on disruptive innovation, particularly around the pilotless aircraft concept.  They are setting up a system to transport drugs by drone out to islands off the coasts from the Netherlands.  He also mentioned the Zipline system that is being used in Rwanda to transport blood products up to 100km to smaller hospitals.  This technology is certainly gaining ground.  We have looked at this for our Northern Territory operations. The problem for us is 100km is a very short distance in the NT.  We would need something that could fly 1000km round trip for it to start to be useful and those machines don’t yet exist – for civilians at least.

The Post-Lunch Conundrum

After lunch the concurrent sessions commenced and with this the concurrence conundrum of which stream to attend.  I went for the ‘Violence in HEMS’ session which was strategically run in the back of the bar in the hotel (so I felt immediately comfortable).

There were no real answers here, just more conundrums. Anne Weaver from London HEMS spoke about the spectrum of violent trauma now seen by their service.  One third of Royal London Hospital trauma patients are now penetrating (which according to Donald Trump could be reduced if more Londoners carried guns).  The figure that surprised me was the number of corrosive liquid attacks now occurring in London being more than 400 a year.  This causes significant disfigurement and appears to be on the rise as means of inter gang violence with perpetrators often quickly escaping on motor cycles.  Not a trend I would hope to see Sydney follow.

Pål Nesfossen gave an overview of the attacks in Oslo from 2011 involving first of all the bomb near the parliament building as a decoy followed by the shootings on the island at a youth camp.  He particularly mentioned the difficulties of determining when a scene is safe and when the incident is over.  When do EMS move in? If it is only when it is all declared completely safe this could be many, many hours which is also unacceptable.

This problem had not been clearly resolved in Norway. Like Australia they have many remote communities and it is not always possible for EMS/fire to stand off in violent incidents waiting for police to arrive.  They have reached a compromise of sorts where EMS always stand off it is a firearm incident.  If not firearm, then the responding personnel (fire and EMS) have some discretion as to whether they enter the scene although the may have to protect themselves or victims using whatever is available, e.g. axes or spades from fire trucks.  The Norwegians do not carry stab vests, and part of the thinking here was that it may lower the threshold for responders to enter a scene if they perceive they are protected.  This is a very controversial area but one that is increasingly going to be debated in prehospital care conferences in the coming years unfortunately.

The second session after lunch followed this theme with a Terrorist attack stream.  Lionel Lamhaut spoke on the Paris attacks from a couple of years ago.  The French appear to be at the other end of the spectrum to the Norwegians where they have physicians embedded in their police ant-terrorism units and the fire brigade is a part of the military.  Hopefully we will never arrive at a point where we believe that EMS should carry weapons.

And Finally, Some Blood

Last session for the day was a stream on massive bleeding.  Dan Hankins gave an overview of the approach used by the Mayo Clinic service in the US for blood products.  They have been carrying red cells since 1988 on their service. CareFlight has carried red cells since at least 1987 perhaps making us the first civilian service in the world to routinely carry them but Mayo was way ahead of us on plasma having carried it since the early 1990s.  We only started with this product a few months ago.  Mayo currently carries an interesting mix of whole blood (1 unit), red cells, plasma and platelets although the exact combination varies a bit depending on availability.  Mayo are the only service in the world routinely carrying platelets that I am aware of.

Wolfgang Voelckel who I mentioned earlier spoke about the FINTIC study (Fibrinogen in Trauma-Induced Coagulopathy) they have been conducting in Austria.  This study involved randomising hypotensive trauma patients to receive either fibrinogen or placebo prehospital.  They were then examining clot strength on arrival in the ED as their end point – it was not sized to assess outcoomes like mortality.  They were able to demonstrate increased clot firmness at ED arrival in patients who had received fibrinogen compared with those that received the placebo.  Early days yet and studies looking at mortality will need to be conducted but fibrinogen is worth watching out for.

Interestingly he noted that some of the patients that received fibrinogen on the basis of prehospital hypotension did not have bleeding identified later in hospital and he postulated that the hypotension was simply on the basis of over sedation.  They are going to have to refine their criteria for inclusion in subsequent studies as fibrinogen has a clear risk of iatrogenic thrombosis (unlike the data on TXA to date) and it should not be thrown around too liberally even without considering the cost.

And that was day 1 for the scientific content.  Then it was off to a very lovely dinner by a lake.  I beat a tactical retreat when my colleague Chris Cheeseman started doing rounds of vodka with the local LPR doctors. This sort of fits with my broader ‘just because you can, doesn’t mean you should…’ ethos.



If this happens to come the way of any other attendees, your reflections would be greatly appreciated.

Otherwise, stay tuned for a review of day 2.