Study: M.D./Helicotpor vs. BLS/Ambulance Trauma Survival

[AnthonyM83]

Too much education related discussion going on right now. Thought I'd throw in an interesting study to change topics.

Prehosp Emerg Care. 2005 Jan-Mar;9(1):79-84.Click here to read Links

HEMS vs. Ground-BLS care in traumatic cardiac arrest.

Di Bartolomeo S, Sanson G, Nardi G, Michelutto V, Scian F.

OBJECTIVE: To assess whether a top-level type of prehospital care, made of helicopter, physician, and advanced life support (ALS) procedures, improves the outcome of blunt trauma victims found in cardiac arrest (CA) as compared with a simpler type, composed of ground ambulance, nurse, and expanded basic life support (BLS).

METHODS: This was a cohort study from the data set of a prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia. RESULTS: Fifty-six victims received the higher level of care (helicopter emergency medical services [HEMS] group) and 73 received the lower one (ground-BLS group). The two groups were homogeneous for mechanism of injury, gender, and time interval before cardiopulmonary resuscitation (CPR). Age was lower in the ground-BLS group. The percentage of patients in which CPR was attempted was significantly higher in the HEMS group (43% vs. 20%; CI 0.061 to 0.379). On-scene return of spontaneous circulation (ROSC) was also more likely in the HEMS group (37.5% of attempted CPRs vs. 6.6%; CI 0.027 to 0.591). None of the patients evacuated from the scene without ROSC ever attained it in hospital. This policy was virtually exclusive to the ground-BLS group. Survival to hospital discharge was 3.5% (severely disabled) in the HEMS group and 0% in the ground-BLS group (CI -0.008 to 0.078).

CONCLUSION: A top-level type of prehospital care had significantly more chances to resuscitate blunt trauma victims found in CA as compared with a simpler level. No significant benefit on long-term outcome was found, but more cases might be needed in future studies because of the inevitably low number of survivors.

[whit72]

Ok. I just have one point to make, the medical helicopters in my area due not transport cardiac arrest victims, whatever the cause. Trauma or medical.

Traumatic arrest pts never live. If you find them without a pulse chances are they are going to stay that way.

So of course the survival rates of pts taken by helicopter will be higher due to the fact that the pt had a pulse when they received them. All their arrests will be witnessed, which as you know has a significant higher level of successful resuscitation. Not nearly as high as medical witnessed arrests.

My thoughts. I don't believe severely disabled is a goal we should be striving to attain.

[spenac]

There are just to many variables for a truly accurate comparison. Also as whit mentioned you don't get back traumatic codes, at least not long term. I did get one back, would not have not had to work but for a stupid doctor on scene. I got him back as far as heart. Intubated and aided respiratory, darted chest, etc, but pupils were blown, he never came around. Worked him again at the hospital but ER doc called it within minutes. Sorry my point is even if get them back it is not a quality return or as study "severe disability" in other words vegetable. This is not a good study to base ALS vs BLS.

[AnthonyM83]

So of course the survival rates of pts taken by helicopter will be higher due to the fact that the pt had a pulse when they received them. All their arrests will be witnessed, which as you know has a significant higher level of successful resuscitation. Not nearly as high as medical witnessed arrests.

I'm not sure if I follow. The article studies only traumatic arrests and says "The two groups were homogeneous for mechanism of injury, gender, and time interval before cardiopulmonary resuscitation (CPR)."

So, there should be no real difference.

The article shouldn't be used for anything definitive, but it still provides interesting information, such as the physician group attempted rescuss more than the BLS group....it might not be too crazy of an idea that they also go more saves.

[spenac]

The article shouldn't be used for anything definitive, but it still provides interesting information, such as the physician group attempted rescuss more than the BLS group....it might not be too crazy of an idea that they also go more saves.

Again though they are not quality saves see "severely disabled". But yes it does prove with more skills available you can do more. But in this case really outcome is no different between the 2 groups. Now if it said no or minor disability then I would say outcome proved ALS over BLS, but don't feel thats valid with this study. No I am not trying to start BLS vs ALS fight. Interesting study though. Thanks for posting it.

[Ridryder 911]

I agree with others. They should never had received any resuscitation efforts to begin with. As noted the only survivors (3.5%) had severelyoutcomes.. Which means ? Brain dead.. TBI.. End Organ ?...

As well, you have to compare their EMS and flight services. One of the pilots I used to work for had worked in EMS Italian Flight service. They utilize large aircraft, and the whole country is smaller than my state. Again, why fly a traumatic arrest other than for the study?

Then again the whole study only had a little more than a 150 patients, in which only < half received ALS care. So the stat.'s can not be accounted as accurate without a large measure of being skewed.

I believe the emphasis should be placed on more how to prevent resuscitation, than attempting to revive the traumatic dead.

R/r 911

[ERDoc]

We are missing a few things from this study. What is their definition of BLS. It looks like they have nurses on the ground, so can they perform IVs? What is their definition of severe disability? Severe may mean something different to me than it means to you. We also need to be careful about the conclusions we draw. Was is the skills provided at the scene? Was it the decreased transport time and quicker time to the OR? Hard to say from this abstract.

[whit72]

Anthony, I was stating in my area. Helicopters dont transport arrest pts. So on arrival if our pt is in arrest we dont even call for the helicopter. So the study would be a mute point in my area.

If we have a pt with traumatic injuries, if we call for the helicopter and that pts arrests before they arrive. They get cancelled. They go by ground. If they are on the ground and they arrest they at times will ride in with us. Not usually though.

As far as the results, a 3.5 percent survival rate and a severly disabled out come is not somthing I would be doing jumping jacks over. I am sure most pts suffering from those those survival rates, wouldnt be either. There is such thing as quality of life over quantity of life.

Just my opinion.

[CBEMT]

I still wouldn't take this study as justification for working a blunt traumatic arrest, no matter who's onscene.

But it doesn't surprise me at all that doctors think they can save these people (no offense ERDoc). In that vein, it may be worthy of note that the only MD-level HEMS service in my area uses ER residents- who I would guess are more likely than anyone to try and play God (thereby getting skills that can be checked off).

[ERDoc]

Whit, this study or a similar one may change that policy (which is why we do studies). If HEMS with an MD can improve outcome then there may be a change in the way we practice.

I took care of a guy in residency who made me reconsider what I felt was a hopeless resuscitation and my feelings on what is considered a bad outcome. I was oncall in the surgical ICU and they helicopter a guy in who was in a high speed motorcycle MVA. He was wearing a helmet. He ended up with an intracranial hemorrhage and a severely elevated ICP. Add to that his flail chest and pneumothorax. He went to the OR prior to sending the evening with me. The neurosurgeon removed a flap of skull, put in a drain and ICP monitor. The guy was on a mannitol drip, intubated and had a chest tube in both sides. The swelling in his brain was so bad that you could see the swelling coming out of the area where the flap had been taken out. His ICP was sky high through the night, to the point where the neurosurgeon stayed in the ICU with me. There was nothing we could do to get his ICP down and the swelling from the flap was getting larger. He went back to the OR and they removed another piece of skull. This one looked the same as the first and didn't help with the ICP. The neurosurgeon talked with the family the next morning and told them that it was pretty much hopeless and they should start making funeral arrangements. He told them that if this guy was to survive he would basically be a vegetable. The following day the next neurosurgeon came on service, who dealt primarily with pediatrics (don't ask how that happened). He told the family that everything was going to be fine :shock: . I left the ICU while he was still there and never heard what happened to him.

A few months later I'm back in the ER and I pickup the guys chart. He is here because he had a seizure while in rehab. He survived, though he will never be the same. He will probably never be able to walk again. He can talk, but with great difficulty (think severe stroke victim). He was a police officer and would never be able to work again or ride a motorcycle. I asked him how he was dealing with everything. He said he was so thankful that he survived. He said that it sucked that he would never walk again and had trouble talking, but he was alive and able to see his girlfriend again. They were planning on getting married once he was up to it. He said he never regretted surviving the accident, despite the degree of disability he has. Made me rethink what it meant to have a severe disability.