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Identification of the Technical and Medical Requirements for HEMS

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Identification of the Technical and Medical Requirements for HEMS Kottmann et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:54 https://doi.org/10.1186/s13049-018-0520-3 ORIGINALRESEARCH Open Access Identification of the technical and medical requirements for HEMS avalanche rescue missions through a 15-year retrospective analysis in a HEMS in Switzerland: a necessary step for quality improvement Alexandre Kottmann1,2* , Pierre-Nicolas Carron1, Lorenz Theiler2,3, Roland Albrecht2, Mario Tissi2 and Mathieu Pasquier1 Abstract Background: Avalanche rescues mostly rely on helicopter emergency medical services (HEMS) and include technical rescue and complex medical situations under difficult conditions. The adequacy of avalanche victim management has been shown to be unexpectedly low, suggesting the need for quality improvement. We analyse the technical rescue and medical competency requirements of HEMS crewmembers for avalanche rescue missions, as well as their clinical exposure. The study aims to identify areas that should be the focus of future quality improvement efforts. Methods: This 15-year retrospective study of avalanche rescue by the Swiss HEMS Rega includes all missions where at least one patient had been caught by an avalanche, found within 24 h of the alarm being raised, and transported. Results: Our analyses included 422 missions (596 patients). Crews were frequently confronted with technical rescue aspects, including winching (29%) and patient location and extrication (48%), as well as multiple casualty accidents (32%). Forty-seven percent of the patients suffered potential or overt vital threat; 29% were in cardiac arrest. The on-site medical management of the victims required a large array of basic and advanced medical skills. Clinical exposure was low, as 56% of the physicians were involved in only one avalanche rescue mission over the study period. Conclusions: Our data provide a solid baseline measure and valuable starting point for improving our understanding of the challenges encountered during avalanche rescue missions. We further suggest QI interventions, that might be immediately useful for HEMS operating under similar settings. A coordinated approach using a consensus process to determine quality indicators and a minimal dataset for the specific setting of avalanche rescue would be the logical next step. Keywords: Avalanche, Rescue, Mission, HEMS, Technical rescue, Clinical exposure, Requirements, Quality improvement * Correspondence: [email protected] 1Emergency Department, Lausanne University Hospital, Lausanne, Switzerland 2Swiss Air Ambulance, Rega, Zürich, Switzerland Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kottmann et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:54 Page 2 of 11 Background The Swiss hospital network contains 12 level-1 trauma Avalanches account for about 100 registered deaths an- centres, eight of which have extracorporeal life support nually in the Alps, around 25 of which occur in capabilities. Rega-Swiss Air Ambulance is the major Switzerland, and these numbers have remained stable HEMS in Switzerland and has 13 bases distributed along over the last 20 years. [1] A large majority of the acci- the Alps and near to the five university hospitals in the dents occur during recreational activities in remote country. Every base is equipped with a single helicopter areas, and the rescue operations are mainly conducted dedicated to HEMS missions and continuously available by helicopter emergency medical services (HEMS). 24/7. The standard crew includes a pilot, a paramedic, Avalanche rescue missions are complex, often combin- and an emergency physician. As for mountain rescue ing search and rescue aspects with medical emergencies missions, a specialist from the Swiss Alpine Rescue may that require specific medical knowledge and skills. [2]In be added to the standard crew. In the specific case of particular, the management of avalanche victims in car- avalanche rescue missions, the HEMS helicopter is how- diac arrest (CA) is complex and has been the focus of ever most of the time dispatched directly to the ava- most of the medical literature on avalanche accidents. lanche site to minimize the response time, and an Because CA in avalanche victims may have several aeti- additional helicopter from a commercial company is dis- ologies, rescuers must integrate numerous specific infor- patched simultaneously to pick up an incident com- mation to guide their management, and dedicated mander, mountain rescue specialists and avalanche dogs algorithms have been developed. [3, 4] if required. However, the compliance to these recommendations has recently been described as unexpectedly low. [4, 5] This may be partially explained by the difficult and haz- Database, variables, and definitions ardous environment in which avalanche rescues take Data were retrospectively analysed from the digital data- place, and by the time pressure and the presumably low set of Rega-Swiss Air Ambulance. [14] The dataset is clinical exposure and experience of the rescuers. [5–8] prospectively registered for resource management and Whatever the reasons, these findings suggest the need activity documentation purposes after every mission, by for quality improvement (QI) in avalanche rescue. the pilot for the operational part and by the physician or A dedicated checklist has been recently proposed to paramedic for the medical part. The operational data in- provide decision-making support during avalanche res- cluded the month and year of the avalanche accident, cue, with the aim to enhance compliance with published the response time (defined as the time interval between algorithms and improve the management of avalanche the alarm and the arrival of the first HEMS helicopter victims. [3, 4, 9, 10] However, a more comprehensive on site), the method used to evacuate the patient from and systematic QI approach has not yet been described the avalanche site, the patient’s destination, and the for avalanche rescue. Baseline measurements are an es- identification number of the crewmembers involved. sential first step of any QI approach, which help to iden- Medical data included the age and gender of the pa- tify potential problem areas. With this study, we tient, the pre-hospital presumptive diagnoses made by therefore provide a baseline measurement through a the HEMS physician, and the diagnostic and therapeutic retrospective analysis of 15 years of avalanche rescue by measures applied on site or during transport. a Swiss HEMS. [11, 12] We aimed to describe the tech- Hypothermia is an item in the predefined list of pre- nical and medical requirements (search, rescue, and sumptive diagnoses of the database and is either deter- medical competencies) of crewmembers. We also evalu- mined clinically by using the Swiss staging system, or by ated their exposure to avalanche rescue missions and measuring a core temperature < 35 °C with an esopha- victims. Finally, the goal of this study is to identify areas geal probe, which is the only available device in our that should be the focus of future QI efforts. HEMS. [15] The severity of the patient’s condition was graded using the eight-level pre-hospital NACA severity score, which is assigned by the HEMS physician at the Methods end of the rescue mission (Additional file 1). [16, 17] Study design and population Text fields of the data set were searched for the fol- We screened all HEMS primary missions from lowing avalanche-specific important information: burial Rega-Swiss Air Ambulance between January 2001 and degree, burial time, and information on the patient’s lo- May 2016. [13] We included data from all patients cation and extrication. Complete burial was defined as caught by an avalanche (regardless of the burial degree), the burial of at least the head and chest. [3] We defined reached within 24 h of the alarm being raised, and trans- multiple casualty accidents as those with more than one ported by the HEMS. Individuals who were not caught caught person. We defined summer avalanches as those by an avalanche were excluded (e.g. bystanders). occurring from June 1st to October 31st. [4, 18] Kottmann et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:54 Page 3 of 11 Study aim differences in the number of rescues were detected be- We aimed to describe the technical and medical require- tween the years (p = 0.257). February was the busiest ments of avalanche rescue missions in terms of search, month, accounting for 27% (n = 113) of avalanche rescues. rescue, and medical competencies of the HEMS crew- Only 2% (n = 7) were summer avalanche rescue missions. members, and to evaluate their clinical exposure to ava- Avalanche accidents involved predominantly middle-aged lanche rescue missions and victims. Based on these males (80% men; mean age 39 ± 13 years). baseline measurements, we aimed to identify and discuss The overall characteristics of the avalanche accidents are operational and medical areas of avalanche rescue mis- shown in Table 1. Box plots of the results presented as sions that should be the focus of QI efforts, and suggest means, IQR and range are available in the Additional file 2. potential QI strategies. Two-hundred-and-seven (80%) of the 258 avalanches for which information about burial degree was available Statistical analysis involved at least one completely buried victim. The me- The data retrieved from the database were exported to dian burial time (available for only 37 completely buried Stata version 14 (Stata Corporation, College Station, TX, victims) was 35 min (IQR 15–60; range 3–1′140).
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