JC: HEMS doesn’t work – at least not for the Dutch

Dutch HEMS from wikipedia
Dutch HEMS from wikipedia

We all love helicopters, don’t we 🙂 We love the idea of swooping from the sky to save a patient at the moment of near death before whisking them off to the Trauma Centre for more life saving surgery, not to mention the tea and medals that will inevitably come.

Surely then it is pretty obvious that helicopters save lives, isn’t it? Or is it? The theoretical benefits of having an experienced and skilled clinician able to attend the severely injured patient almost immediately appear obvious. They can assess the patient, instigate immediate treatment and liaise with other medical staff to ensure the appropriate services are ready and waiting at the hospital: this should all combine to improve the outcome for the patients in a way that should be apparent and measurable. Well in theory it should, but to be sure we should really look at some data to see if there is any evidence for the role of helicopters in improving outcome from trauma.

So it was with this in mind that we selected a paper entitled ‘The effect of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands’, published in Injury, for this week’s Journal Club at St.Emlyn’s. You will probably know that Virchester has an ambulance helicopter but that it is relatively new to the scene and has only recently started carrying doctors. The city is therefore on a bit of a learning curve on how it will impact on trauma care.

Now, to this interesting paper asking a pretty relevant question: ‘Does a helicopter emergency medical service (HEMS) improve patient outcome in trauma?’

In this retrospective study from the Netherlands, the authors looked at patients who had suffered trauma (Ed – good that’s the group of patients we are interested in), and to see how the helicopter affected mortality the authors matched patients who had been seen by the HEMS with patients who had not been seen by HEMS. Patients were matched according to ISS, age and the presence or absence of severe traumatic brain injury.

It is important to note that the HEMS service in the Netherlands is different to that provided in other countries. The service is all about bringing the hospital (or at least a surgeon or an anaesthetist) to the critically ill patient rather than bringing the patient to the hospital. In other countries with different geographic conditions the priority is often about transporting the patient by helicopter in order to reduce the pre-hospital time. In this study, the majority of patients who were treated by the HEMS team were still transported to hospital by road ambulance. So this is about moving the doctors as much as it is about moving the patient. An interesting model and quite different to what we try and do in the UK.

[learn_more caption=”So what did they find?”] Ok, the first issue is that this study is retrospective, although in this paper this is not as big a problem as it might have been the data is already recorded prospectively as part of a nationwide registry. The authors compared all the patients with trauma for whom HEMS attended over a five year period with matched trauma patients who were not seen by the HEMS team over the same time period. The patients were matched in terms of ISS, blunt or penetrating mechanism, age, sex and presence of traumatic brain injury.

The authors looked at the Day 1 mortality rates and the total in-patient mortality rates for each of the two groups of patients. They also sub-divided them into traumatic brain injury (TBI) and non-TBI patients. They found a slight increase in in-hospital mortality in the HEMS group for patients with TBI and a slight reduction in mortality for non-TBI patients. Neither of the results were significant with very large confidence intervals each way.

Mortality is a pretty hard outcome so we are not overly concerned about the lack of blinding.

They did find that patients where HEMS were involved spent significantly longer at scene, took longer to get to hospital and were much more likely to be intubated. These findings are not surprising but the question remains as to whether this was beneficial or detrimental to the patient outcome.

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[learn_more caption=”This is the next issue, were the two populations comparable at baseline?”] Probably not. Despite the matching that has been done, there must have been some reason that the HEMS team were called or not called. The authors have provided the criteria that the ambulance crew use to decide if they need to call HEMS which does include criteria such as multiple victims at scene and specific mechanisms of injury such as ejection from a vehicle or explosion. It would be reasonable to assume that HEMS were more likely to be called in for more serious incidents although this may not be reflected in the injury severity score. In fact, we would argue that the two groups are intentionally different at baseline. HEMS gets called for one set of criteria, ground ambulance for those that don’t meet the criteria (Ed – it’s all there in table 1), so although there is some matching it is highly likely that we are comparing apples and oranges here. There is an expectation that the HEMS group would be more seriously injured.

But matching for ISS should sort this shouldn’t it?

Using ISS is one way of matching patients in a study of this kind as we could argue that having patients with similar levels of anatomical injury is comparable……or is it? As resuscitationists, we know that the anatomical injury is but one part of the problem. It is the effect on the victims physiology that holds our focus in the resus room. However, the authors did not take this into account in the matching process.

One scoring system that may reflect how physiologically sick the patients were, is the revised trauma score (RTS). This includes physiological parameters to show any clinical decompensation in response to the injury. This was recorded but unfortunately the authors were not able to match the patients for this due to ‘practical reasons’. It may be that it was not possible to match this due to the limited size of the patient population available. This was adjusted for in the multivariate logistic regression but was significantly different at baseline in the two groups.

One stage further would have been to combine physiological, age and anatomical data into a survival prediction tool. TRISS is probably one of those that you are most familiar with, but do follow this link to the TARN site for an online survival calculator for trauma based on European data. Something like this could have been used to match patients against probability of survival rather than just anatomical injury.

[blackbirdpie url=”https://twitter.com/JC_StE/status/287188612410380288″]

[blackbirdpie url=”https://twitter.com/johnboy237/status/287188030140338177″][/learn_more]

[learn_more caption=”So what do we know?”] There were some issues about the methods of this study in terms of matching true control patients, and the patients were significantly different in terms of RTS at baseline. This means that there are inherent biases around patient selection and comparability in this study. Without assurances about the comparability of the groups then any further analysis is going to be risky.

There was no attempt at a sample size calculation but given the non-significant results one suspects that a larger study may have been more conclusive if there is truly a difference to find. This study suggests that if HEMS does make a difference it is not massive enough to be reliable demonstrated with the numbers here (though to be honest the effect would have to be very large with this size of cohort). The geeky ones in Journal Club spotted some unusual methods in the statistics (like using t-tests for comparing RTS data – almost certainly not the right test), but our fundamental concerns were really about the overall method and patient selection rather than the analysis. No amount of clever (or not) analysis can compensate for fundamental methodological flaws.

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[learn_more caption=”Where next?”] The ideal study to answer this question would be a large, prospective, multi-centre, randomised controlled trial comparing HEMS vs. non-HEMS care for trauma patients. The presence of a large data-base would probably also provide information about more subtle outcomes than simple survival.

RCTs may be difficult to achieve though as randomising patients to not get the very expensive, all singing, all dancing shiny helicopter will always be tricky and the ethical questions were highlighted in the online journal club discussions.

[blackbirdpie url=”https://twitter.com/FrankandErrol/status/287186748449103874″]

So what about other methods? One model would be a before and after study such as this one from Scandinavia published this year.

acta helo paper

An alternative approach would be to look at very large databases with access to patient data and outcomes as this article in JAMA did last year.

 JAMA helo paper

Both of these articles suggest a survival benefit although one could still criticise the methodology for not being of a perfect design.

Perhaps then we need to think a little more broadly on this subject and consider whether we are really looking at helicopters or whether we are looking at trauma systems. You can’t have one without the other after all, but the focus of many studies revolves around the aircraft and not the system as a whole. This is perhaps not the place to consider the risks/benefits of HEMS, rather it’s a really good paper to stop and think carefully about what we are reading before coming to any firm decision on whether we can use this data for the benefit of our own patients.

Sadly the absence of really well executed trials means that HEMS is seen by some as an expensive service to provide with very little evidence of benefit despite the obvious theoretical ‘fact’ that it should work.

As EBM practitioners, we need to be careful how we interpret the data and methods used within the description of the trauma systems being analysed. This is a good example of how a retrospective, small study with inherent biases may not quite answer the question asked.

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Craig Ferguson

 

 

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Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

  1. Dutch HEMS currently embarrassingly crippled by politics . What is not published here is Dutch Anaesthetics current complete absence from all HEMS operations. This data is from year 3 or 4 Surgical trainees operations !!! None of these doctors provide anaesthetics or Critical Care as part of their normal jobs.

    Reply

    1. Thanks (anonymous poster). I think that is borne out in the blog post that papers at first glance seem to be focusing on the method of transportation, but it is the systems in which they operate which are just as important.

      In your comment you mention the skill mix on the Helo which is interesting. Again, that is a systems factor rather than the mode of transport. I cannot triangulate your comments from the paper, but if true then certainly very interesting.

      I hope you agree that this demonstrates the need to read papers fully and not just the title and abstract….!

      Thanks again.

      S

      Reply

  2. Simon, Craig, thankyou. The evidence base in this area is limited at best.
    I think it depends on the geography of Virchester and how severely injured you are
    there is no doubt it is all about a robust integrated trauma system as well. Two good historical case studies to highlight this are Princess Diannas car accident and Senator Gabrielle Giffords shooting incident. In Gifffords case, HEMS units were stood down when decision to road transport her was made by onscene paramedics. She is alive and out of hospital today likely as a result of rapid road transport rather than comprehensive prehospital critical care.

    one of the largest RCT trials of prehospital doctor led HEMS care for severe TBI in Sydney, the HIRT trial, failed to show a mortality difference as primary outcome cw road ambulance paramedic led care. It had significant issues in methodology and recruitment which highlights the problems of conducting robust trials in this setting.

    some things to consider in addition are cost and safety. there is no dispute that HEMS is expensive and safety is a major issue.

    So to me distance , geography and severity of injury are the critical factors in deciding the role of HEMS in trauma care, just as they are on the battlefield, where there are few roads, injuries are often multiple and severe and the geography is hostile.

    The British MERT teams using Chinook helicopters, bring ED resus room care to the frontline and their retrospective analysis of their work in Afghanistan shows a surprising number of survivors of injuries that would have expected to been universally lethal i.e GSW to head, severe thoracic penetrating trauma, bilateral limb losses.

    So perhaps dont look at DUtch HEMS data but at your own military medevac data. Go the Poms!

    Reply

    1. Absolutely. The difficulty I see is that a lot of prehospital trials are interpreted without really looking hard at the setting, systems, people and cases.

      We like these sort of papers at @JC_StE as they help us bring out the need for structured Critical Appraisal.

      My biggest beef was with the attempt to compare groups that seem to be quite different at baseline. A really good argument for RCTs, but tricky to do with a shiny helicopter not getting scrambled.

      Next question would be do you need to do an RCT if you don’t believe that clinical equipoise exists…..?

      S

      Reply

  3. Is this the article you’re discussing?
    http://www.ncbi.nlm.nih.gov/pubmed/22305588

    I don’t know poster “rescue” where you got your information from, but as a former colleague of the authors, I know for sure that the data used here is from HEMS operations staffed with anaesthetists or trauma surgeons alongside a flight nurse. No (surgical) trainees were involved whatsoever.

    So please explain your comment further. Thank you!

    Nienke

    Reply

  4. I agree with you Minh that you can’t compare the UK with the Netherlands.
    Our country is so small that for allmost all (trauma) patients a hospital is nearby and reached by ambulance quickly.
    An emergency helicopter is rarely used for patient transport, again a difference.
    The question is, will bringing a specialist to the scene benefit the patient? We are studying this right now, lokally, in our own region (university hospital Nijmegen) to get the answers. Keeping an expensive bird flying needs to be the right thing and not just fun…

    Nienke

    Reply

  5. Andreas Krüger January 10, 2013 at 9:12 am

    Interesting discussion!! The key for assessing HEMS studies is to first intepret the context in which the pre-hospital care is provided. The importance of fixed system factors is paramount and also recommended in the litterature : http://www.ncbi.nlm.nih.gov/pubmed/22107787 That might be done this way : http://www.ncbi.nlm.nih.gov/pubmed/20122784, or by requesting a detailed system factor description by journals. (Excuse me for citing myself here..)
    We all aim to increase the value of the care we provide don’t we? vaule can be expressed as quality (outcome) divided by costs, and that leaves us with the choice to either increase quality, reduce cost or (best) both…. Until we have robust indicators of quality, we have little clue of the value of our way of organising pre-hospital care. Therefore; QIs in pre-hospital care is deeply needed. In a coming paper assessing prospectively all physician-staffed pre-hospital services in Scandinavia( covering half of the population in Scandinavia) we find these services doing far more medical missions (about 65% of all) than trauma. And in up to 65 % of the patient encounters the patient were after study definition critically ill or injured. Patients had preliminary diagnoses all across the ICD-spectrum. But, thats in a context with laong distances, and centralised advanced medical definitive treatment. I guess one way to improve value for HEMS is to assess it own context, construct the activity according to this context and refind triage/ dispatch practise accordingly.

    Reply

Thanks so much for following. Viva la #FOAMed

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