William R. Hinckley

Ground Emergency Medical Services Requests for Helicopter Transfer of ST-segment Elevation Myocardial Infarction Patients Decrease Medical Contact to Balloon Times in Rural and Suburban Settings

OBJECTIVES   ST-segment elevation myocardial infarction (STEMI) care is time-dependent. Many STEMI patients require interhospital helicopter transfer for percutaneous coronary intervention (PCI) if ground emergency medical services (EMS) initially transport the patient to a non-PCI center. This investigation models potential time savings of ground EMS requests for helicopter EMS (HEMS) transport of a STEMI patient directly to a PCI center, rather than usual transport to a local hospital with subsequent transfer. METHODS   Data from a multicenter retrospective chart review of STEMI patients transferred for primary PCI by a single HEMS agency over 12 months were used to model medical contact to balloon times (MCTB) for two scenarios: a direct-to-scene HEMS response and hospital rendezvous after ground EMS initiation of transfer. RESULTS   Actual MCTB median time for 36 hospital-initiated transfers was 160 minutes (range = 116 to 321 minutes). Scene response MCTB median time was estimated as 112 minutes (range = 69 to 187 minutes). The difference in medians was 48 minutes (95% confidence interval [CI] = 33 to 62 minutes). Hospital rendezvous MCTB median time was estimated as 113 minutes (range = 74 to 187 minutes). The difference in medians was 47 minutes (95% CI = 32 to 62 minutes). No patient had an actual MCTB time of less than 90 minutes; in the scene response and hospital rendezvous scenarios, 2 of 36 (6%) and 3 of 36 (8%), respectively, would have had MCTB times under 90 minutes. CONCLUSIONS   In this setting, ground EMS initiation of HEMS transfers for STEMI patients has the potential to reduce MCTB time, but most patients will still not achieve MCTB time of less than 90 minutes.

Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.

BACKGROUND Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. METHODS This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. RESULTS The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2–75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01–1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, −5% to 42%). CONCLUSION In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Reperfusion is delayed beyond guideline recommendations in patients requiring interhospital helicopter transfer for treatment of ST-segment elevation myocardial infarction.

STUDY OBJECTIVE Early reperfusion portends better outcomes for ST-segment elevation myocardial infarction (STEMI) patients. This investigation estimates the proportions of STEMI patients transported by a hospital-based helicopter emergency medical services (EMS) system who meet the goals of 90-minute door-to-balloon time for percutaneous coronary intervention or 30-minute door-to-needle time for fibrinolysis. METHODS This was a multicenter, retrospective chart review of STEMI patients flown by a hospital-based helicopter service in 2007. Included patients were transferred from an emergency department (ED) to a cardiac catheterization laboratory for primary or rescue percutaneous coronary intervention. Out-of-hospital, ED, and inpatient records were reviewed to determine door-to-balloon time and door-to-needle time. Data were abstracted with a priori definitions and criteria. RESULTS There were 179 subjects from 16 referring and 6 receiving hospitals. Mean age was 58 years, 68% were men, and 86% were white. One hundred forty subjects were transferred for primary percutaneous coronary intervention, of whom 29 had no intervention during catheterization. For subjects with intervention, door-to-balloon time exceeded 90 minutes in 107 of 111 cases (97%). Median door-to-balloon time was 131 minutes (interquartile range 114 to 158 minutes). Thirty-nine subjects (21%) received fibrinolytics before transfer, and 19 of 39 (49%) received fibrinolytics within 30 minutes. Median door-to-needle time was 31 minutes (interquartile range 23 to 45 minutes). CONCLUSION In this study, STEMI patients presenting to non-percutaneous coronary intervention facilities who are transferred to a percutaneous coronary intervention-capable hospital by helicopter EMS do not commonly receive fibrinolysis and rarely achieve percutaneous coronary intervention within 90 minutes. In similar settings, primary fibrinolysis should be considered while strategies to reduce the time required for subsequent interventional care are explored.

Helicopter Scene Response for a STEMI Patient Transported Directly to the Cardiac Catheterization Laboratory

At 2:10 pm, a 40-year-old Caucasian woman with no known medical history called 911 complaining of substernal, crushing chest pain that had started 2 to 3 hours before she called emergency medical services (EMS). EMS arrived at 2:24 pm and obtained a 12-lead electrocardiogram (ECG) diagnostic of ST-segment elevation myocardial infarction (STEMI) at 2:36 pm. University Air Care was requested by local EMS at 2:42 pm to respond directly to the cardiac scene in rural Ohio for rapid transport to a facility capable of performing percutaneous coronary intervention (PCI). The closest PCI-capable facility was approximately 35 minutes away by ground or 13 minutes by air. The closest non-PCI hospital was approximately 20 minutes away by ground (Fig. 1).

Transporting the pregnant patient in shock: case report and review.

Perhaps no patient population invokes more dread in the prehospital setting than the sick pregnant patient. Assessing the pregnant patient in shock requires identifying sources of potential shock, knowledge of the unique physiologic changes of pregnancy influencing initial therapies, and transporting in an efficient manner to maximize benefit to the patient and expedite the transfer to definitive obstetric care. Here we present a case of air medical transport of a pregnant patient in shock with a review of the relevant literature. Case Report Air medical transport was dispatched to a rural community college for a 37-year-old woman found on the floor in a restroom 35 weeks pregnant and complaining of abdominal pain. The patient denied any trauma to the abdomen or spontaneous rupture of membranes but stated that she had been having unrelenting pain in her abdomen for approximately 30 minutes. She denied contractions but described a sharp stabbing sensation extending from her xiphoid process to her pelvis. She denied any vaginal bleeding or loss of consciousness but complained of extreme dyspnea. The patient had a history of two live births via cesarean section and five miscarriages due to anti-phospholipid antibody syndrome for which she was on daily heparin injections for thrombosis prophylaxis. On examination, she was ill-appearing and tachypneic with a respiratory rate of 38 breaths/min, a pulse of 100 beats/min, and blood pressure of 76/44 mmHg. Oxygen saturation was 100% on nonrebreather mask. Her abdomen was distended, gravid, and tender to palpation without ecchymosis or palpable contractions. Her extremities were noted to be cool and pale. She was able to follow commands but was mildly confused and combative. Emergency medical services had established a 20-gauge intravenous line with normal saline. The patient continued on nonrebreather while fluids were switched to pressure infuser. She was transferred to the aircraft on a wedge under the right side. A second intravenous line was established. During the 10-minute flight, medical control arranged for transport directly to the operating room because of her persistent hypotension. On arrival the obstetrical team performed an emergent midline classical cesarean section, with the fetus noted to be free-floating outside a ruptured uterus. Approximately 3 liters of blood were evacuated. Simultaneous delivery of the infant and resuscitation of the mother occurred while the obstetric and trauma teams packed the abdominal cavity and primarily repaired the uterus. The infant was resuscitated for an hour without success. The patient had a prolonged hospitalization but ultimately recovered completely.

Critical Burn Patient with an Unknown Neuromuscular Disease

The following is a recount of an actual patient case involving air transport. Minor details of the case may have been changed, solely to protect the privacy of the patient. The initial presentation and treatment will be described, followed by several questions, in this issue. Readers are invited to submit responses to the questions and other thoughts or comments to David Ross, DO, at DRDR0682@aol.com . In the next issue, relevant reader responses will be published. We will conclude the case in the next issue with a discussion of how the patient was actually managed, the outcome, a review of the related medical literature, and interviews with medical/transport experts, where appropriate. We strongly encourage reader participation. If you have a case that might be suitable as a subject for Case Review, please submit the details to David Ross at the above email address.

Critical Burn Patient with an Unknown Neuromuscular Disease: Conclusion

A 37-year-old man was severely burned while trying to fill a lighter with fuel while smoking. He sustained full-thickness (third-degree) burns over 60% to 70% of his body, including the oropharynx. A ground-based paramedic was unable to orotracheally intubate the patient after the administration of morphine and diazepam. The flight crews assessment found an awake, alert man who was unable to speak because of his oral injuries. The Glasgow Coma Scale was estimated to be 10. In addition, the patient was wheelchair-bound from an undefined neuromuscular disease. The patient was successfully intubated by the flight team as in the following description.