The benefits of HEMS – more than just statistics!

As demonstrated by the previous post, studies that show a benefit for HEMS receive significant exposure within the medical and prehospital community. Due to the nature of the work, often relatively short times providing care to patients, and heterogeneity of patient/pathology/environment, benefits in terms of statistically significant improved patient outcomes are difficult to demonstrate.

In this post, I thought I’d outline some of the non-measurable benefits that have resulted from the advent of the Auckland HEMS (specifically by combining the existing paramedic/crewman team with a hospital-based doctor).

1) Improved understanding influencing ED care

Those of us who have ventured into the prehospital environment have gained a new understanding of the specific challenges involved, including those around the interface between the prehospital and hospital environment. With our newfound experience and the guidance of our paramedic colleagues from St John and ARHT, the way patients are handed over by prehospital staff and received by ED staff has evolved. This is best explained in this post, which contains a video demonstrating an effective handover template and use of a whiteboard for significantly unwell patients. As an ED doctor receiving patients and leading a resus team , this sort of process feels like  significant improvement in patient care – even if proving it with statistics would be just about impossible!

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Auckland ED ambulance bay

2) More communication and teamwork

While working in HEMS, we have built relationships with pilots, crewmen, paramedics, and other ARHT employees. What has been surprising however is the extent to which communication has changed between ED doctors (not just the HEMS doctor team) and our St John paramedic colleagues who are NOT directly involved with the Westpac Helicopter. In addition to evolved handovers as discussed above, there seems to be a lot more dialogue between paramedics and doctors in our ED. We are fielding more questions and requests for feedback about patients that are delivered to us, more clinical queries and requests for information in general, requests for paramedics to attend ED mortality/morbidity reviews where appropriate. Speaking for myself, this a two way process – with more of an understanding of how the prehospital setting works, I can now request additional information from paramedics with the aim of improving the care I deliver.

Recently, the benefits of more communication and dialogue were demonstrated to me when two St John paramedics who had delivered a critically ill trauma patient became active resus team members a considerable time after their handover. I was leading a team dealing with severe haemorrhagic shock, a massive transfusion requirement, extremely poor vascular access, a reduced LOC, and a predicted difficult airway. The patient also had multiple long bone fractures, and with all the doctors in my team tied up dealing with the other issues, the two paramedics rapidly and effectively splinted the fractures for me. (Thanks guys – and feel free to leave your Sager traction splint in the ED annnnny time you like…!) I am unsure whether this sort of collaboration would have occurred prior to the ‘cultural change’ that seems to have arrived since the advent of HEMS, but now it feels like there are no barriers in place.

A valuable addition to the ED team..

A valuable addition to the ED team..

3) Active safety management

Placing hospital-based doctors in an aeromedical setting exposes them to the systems required in aviation, including those regarding safety management (watch this video if you haven’t already!) Medicine is traditionally some years behind aviation with regards to active safety management, and while aviation systems cannot be directly be ported directly to medicine (this, plus the process of moving on from aviation learnings into ED-relevant material is discussed on Resus Room Management – a great site that is well worth a look), there is much we can learn.

The involvement of the helicopter crewman in the medical resuscitation team lent itself well to checklist use (crewman have a lot of experience with checklists!), and the Auckland HEMS RSI checklist was the end result. The familiarity with checklists has started another culture change in our ED, and people are starting to realise their value. While Auckland ED has not yet adopted a formal RSI checklist, versions are already being used in our resus rooms, and have the potential to significantly improve the safety of our advanced airway management.

Involvement in HEMS has also allowed the medical team to gain experience with an online safety management system. ARHT uses Air Maestro, which is now being used by the trust to cover medical as well as aviation issues (many thanks to Armin Egli and Paul Robinson for sorting this one out!). While introducing something like this to ED would be a difficult undertaking, gaining experience with it through HEMS allows us to explore the medical uses while seeing in real-time how it improves the safety of aviation operations. Food for thought…

The comments above represent my thoughts about some of the non-measurable benefits of the Auckland HEMS trial. I’d love to hear your thoughts, please post comments below if you wish.

 

Paramedics in high-stress simulation: performance may be affected

In a recent study from Toronto, researchers studied paramedics in two similar scenarios. Both scenarios involved a 50 year old patient suffering from chest pain. The patient develops pulmonary edema, hypotension and an ECG reveals a STEMI. All study participants (paramedics) performed interventions based on their established local protocols.

In the “high stress” scenario, there was an actor playing the patient’s partner who was visibly distressed and challenging the paramedic’s actions. Also, all alarms were turned up to full volume and there was constant 2-way radio communication going on in the background. None of this occurred in the “low stress”  scenario.

Paramedics were assessed using a global rating scale, a checklist scale and their salivary cortisol levels were measured before and after each scenario (as a response to stress).

The authors noted that “When faced with clinically relevant stressors, paramedics demonstrated significant increases in subjective (anxiety) and physiological
(salivary cortisol) measures of stress. These stress responses were accompanied by impairments in some aspects of clinical performance and in the ability to accurately recall information from the case. Although the paramedics demonstrated no impairments in
their ability to complete each individual action required for the particular scenario, decreased scores on the global rating scale indicate that overall they did so more poorly, with less organization and poorer communication or interpersonal skills.” 

Overall, paramedics did feel more stressed in the “high stress” scenario – this was measured both by a survey and cortisol levels. And while they were able to complete all relevant tasks, their global performance assessment was reduced as was their ability to recall specific case details.

Fascinating study! We must recognize the high potential for error among clinicians when faced with stress.This data should guide us towards the increasing use of emergency checklists so that things are not forgotten in stressful environments,  Such findings will lead nicely into a new video by Scott Orman about the use of whiteboards in handovers and the potential for inaccurate data transmission (unless there’s protocols in place to document better!).

These authors also did a similar study with residents – with similar findings! We need to do better as clinicians & educators in recognizing stress as a huge factor leading to errors and implement interventions to manage these potential threats and errors.

Here’s the abstract

The impact of stress on paramedic performance during simulated critical events.Prehosp Disaster Med. 2012 Aug;27(4):369-74. Epub 2012 Jul 25. Leblanc VR, Regehr C, Tavares W, Scott AK, Macdonald R, King K.

Abstract

OBJECTIVES:

Substantial research demonstrates that the stressors accompanying the profession of paramedicine can lead to mental health concerns. In contrast, little is known about the effects of stress on paramedics’ ability to care for patients during stressful events. In this study, we examined paramedics’ acute stress responses and performance during simulated high-stress scenarios.

METHODS:

Twenty-two advanced care paramedics participated in simulated low-stress and high-stress clinical scenarios. The paramedics provided salivary cortisol samples and completed an anxiety questionnaire at baseline and following each scenario. Clinical performance was videotaped and scored on a checklist of specific actions and a global rating of performance. The paramedics also completed patient care documentation following each scenario.

RESULTS:

The paramedics demonstrated greater increases in anxiety (P < .05) and salivary cortisol levels (P < .05) in response to the high-stressscenario compared to the low-stress scenario. Global rating scores were significantly lower in the high-stress scenario than in the low-stress scenario (P < .05). Checklist scores were not significantly different between the two scenarios (P = .12). There were more errors of commission (reporting information not present in the scenario) in the patient care documentation following the high-stress scenario than following the low-stress scenario (P < .05). In contrast, there were no differences in omission errors (failing to recall information present in the scenario) between the two scenarios (P = .34).

CONCLUSION:

Clinical performance and documentation appear vulnerable to the impact of acute stress. This highlights the importance of developing systems and training interventions aimed at supporting and preparing emergency workers who face acute stressors as part of their every day work responsibilities.

Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)

HEMS: Lessons from Helicopters to Fast Response Cars

This video shows a superb talk by Dr Gareth Davies, Clinical Director of the London HEMS. Topics covered include the role and structure of the service, the risks involved, and how those risks are mitigated with lessons learned from aviation.

This video comes from Risky-Business.com, a collaboration between various UK and USA hospitals and institutions which focuses on risk management and human factors in the medical setting.

Click here to watch the video.