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.
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.
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.
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.
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.
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!
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…
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.