La vitesse ne fait pas tout

Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport.

Chen X et Al.  J Trauma Acute Care Surg. 2018 Apr;84(4):549-557

 

------------

Ne pas perdre de temps est bien. Mais il ne faut pas oublier également que la réalisation de gestes avancés de réanimation est aussi utile en préhospitalier. Ceci milite pour la constitution d'équipes dont l'expertise en matière de gestion des voies aériennes/Trauma thoracique-Crânien est le métier. Cette question se pose tout particulièrement pour les vecteurs d'EVASAN à voilure tournante.

------------ 

BACKGROUND:

Helicopter emergency medical services (HEMS) have demonstrated survival benefits over ground emergency medical services (GEMS) for trauma patient transport. While HEMS speed is often-cited, factors such as provider experience and level of care may also play a role. Our objective was to identify patient groups that may benefit from HEMS even when prehospital time for helicopter utilization is longer than GEMS transport.

METHODS:

Adult patients transported by HEMS or GEMS from the scene of injury in the Pennsylvania State Trauma Registry were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS, keeping only pairs in which the HEMS patient had longer total prehospital time than the matched GEMS patient. Mixed-effects logistic regression evaluated the effect of transport mode on survival while controlling for demographics, admission physiology, transfusions, and procedures. Interaction testing between transport mode and existing trauma triage criteria was conducted and models stratified across significant interactions to determine which criteria identify patients with a significant survival benefit when transported by HEMS even when slower than GEMS.

RESULTS:

From 153,729 eligible patients, 8,307 pairs were matched. Helicopter emergency medical services total prehospital time was a median of 13 minutes (interquartile range, 6-22) longer than GEMS. Patients with abnormal respiratory rate (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.26-4.55; p = 0.01), Glasgow Coma Scale score of 8 or less (OR, 1.61; 95% CI, 1.16-2.22; p < 0.01), and hemo/pneumothorax (OR, 2.25; 95% CI, 1.06-4.78; p = 0.03) had a significant survival advantage when transported by HEMS even with longer prehospital time than GEMS. Conversely, there was no association between transport mode and survival in patients without these factors (p > 0.05).

CONCLUSION:

Patients with abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from HEMS transport even when GEMS transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center.

MEDEVAC de la BSS: En gros que fait on ?

Forward medevac during Serval and Barkhane operations in Sahel: A registry study.

Carfantan C, et Al. Injury. 2017 Jan;48(1):58-63.

-----------------------------------

Une activité particulièrement sensible dont la lecture permet de comprendre toute la complexité de la prise en charge de nos soldats dans un contexte d'élongation majeure. On comprend également tous les enjeux de positionnement d'équipes sanitaires ayant la maîtrise de certaines pratiques avancées de réanimation préhospitalière.

-----------------------------------

 

INTRODUCTION:

The French army has been deployed in Mali since January 2013 with the Serval Operation and since July 2014 in the Sahel-Saharan Strip (SSS) with the Barkhane Operation where the distances (up to 1100km) can be very long. French Military Medical Service deploys an inclusive chain from the point of injury (POI) to hospital in France. A patient evacuation coordination cell (PECC) has been deployed since February 2013 to organise forward medical evacuation (MEDEVAC) in the area between the POI and three forward surgical units. The purpose of this work was to study the medical evacuation length and duration between the call for Medevac location accidents and forward surgical units (role 2) throughout the five million square kilometers French joint operation area.

MATERIALS AND METHODS:

Our retrospective study concerns the French patients evacuated by MEDEVAC from February 2013 to July 2016. The PECC register was analysed for patients' characteristics, NATO categorisation of gravity (Alpha, Bravo or Charlie who must be respectively at hospital facility within 90min, 4h or 24h), medical motive for MEDEVAC and the time line of each MEDEVAC (from operational commander request to entrance in role 2).

RESULTS:

A total of 1273 French military were evacuated from February to 2013 to July 2016; 533 forward MEDEVAC were analysed. 12,4% were Alpha, 28,1% Bravo, 59,5% Charlie. War-related injury represented 18,2% of MEDEVAC. The median time for Alpha category MEDEVAC patients was 145min [100-251], for Bravo category patients 205min [125-273] and 310min [156-669] for Charlie. The median distance from the point of injury to role 2 was 126km [90-285] for Alpha patients, 290km [120-455] km for Bravo and 290km [105-455] for Charlie.

CONCLUSIONS:

Patient evacuation in such a large area is a logistic and human challenge. Despite this, Bravo and Charlie patients were evacuated in NATO recommended time frame. However, due to distance, Alpha patients time frame was longer than this recommended by NATO organisation. That's where French doctrine with forward medical teams embedded in the platoons is relevant to mitigate this distance and time frame challenge.

Evasan stratégiques: Que fait on ?

Clic sur l'image pour accéder au document

Un nouveau concept de triage ?

Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011

Clarke JE et Al. Mil Med. 2012 Nov;177(11):1261-6

--------------------------------------------------------------------

Un article de synthèse sur l'organisation de la chaîne de prise en charge des blessés par nos confrères anglais, avec notamment l'emploi d'une évolution majeure pour le un système anglo-saxon (lire ce document): le recours à des EVASAN médicalisées par des personnels ayant une pratique régulière de la prise en charge de patients en état critique. Cet article est intéressant car il insiste sur l'importance du triage et le rôe prééminent que peuvent jouer les role 2 notamment si les élongations sont importantes.

-------------------------------------------------------------------- 

Medical evacuation of combat casualties in Operation Enduring Freedom-Afghanistan is achieved primarily by helicopter, because of distances involved as well as ground-based threats. In Helmand Province, evacuation from the point of injury may occur on a variety of helicopter evacuation platforms with disparate levels of attendant medical expertise. Furthermore, triage to a medical treatment facility may involve varying echelons of care before definitive management. Consequently, considerable differences in medical care may be encountered between point of injury and definitive treatment. We discuss the role of helicopter-based medical evacuation in Helmand, Afghanistan, as well as triage and timelines to the most appropriate medical facilities. Based on our experience and available evidence, we have made recommendations to regional commanders which favor the utilization of prehospital critical care teams aboard helicopter-based evacuation platforms and direct triage to the highest echelon of care available when feasible

Médecin EXPERIMENTÉ: Pronostic amélioré

Determining the composition and benefit of the pre-hospital medical response team in the conflict setting

Davis PR et Al. J R Army Med Corps. 2007 Dec;153(4):269-73

----------------------------------------------------------------

La composition des équipes d'evasan tactique fait débat. La présence d'un médecin serait associée à une meilleure survie des blessés les plus graves, surtout si les délais de prise en charge par une équipe chirurgicales sont longs. Encore faut il que ce médecin ait de réelles compétences en matière de traumatologie et d'exercice de la médecine préhospitalière en situation isolée.

---------------------------------------------------------------- 

Aim: To determine the optimal composition of the pre-hospital medical response team (MERT) and the value of prehospitalvcritical care interventions in a military setting, and specifically to determine both the benefit of including a doctor in the pre-hospital response team and the relevance of the time and distance to definitive care.

Method: A comprehensive review of the literature incorporating a range of electronic search engines and hand searches of key journals.

Results: There was no level 1 evidence on which to base conclusions. The 15 most relevant articles were analysed in detail. There was one randomized controlled trial (level 2 evidence) that supports the inclusion of a doctor on MERT. Several cohort studies were identified that analysed the benefits of specific critical care interventions in the pre-hospital setting.

Conclusions: A doctor with critical care skills deployed on the MERT is associated with improved survival in victims of major trauma. Specific critical care interventions including emergency endotracheal intubation and ventilation, and intercostal drainage are associated with improved survival and functional recovery in certain patients.

Medevac tactique:Médicalisation utile pour 30% des blessés

En-Route Care Capability From Point of Injury Impacts Mortality After Severe Wartime Injury

Morrison JJ et AL. Ann Surg 2013;257: 330–334

 

Il est difficile de se faire une idée de l'efficience de nos organisations de relève des blessés de guerre. En effet les 2/3 de ses derniers sont peu graves et ne nécessitent pas de pratiques avancées. Le conflit afghan a permis de confirmer la pertinence d'un certain nombre de faits: Une stratégie de conditionnement basé sur l'analyse des causes évitables de décès, l'importance de la mise en place d'un réseau structuré de prise en charge préhospitalière et hospitalière. Ce document confirme que la médicalisation avancée améliore la probabilité de survie des  blessés de gravité intermédiaire qui représentent tout de même près du  1/3 des cas rencontrés et qui justifient nos organisations. Ceci confirme que la maîtrise de pratiques de base de réanimation préhospitalière devrait donc être l'un des piliers de l'organisation des évacuations médicales tactiques. 

 

OBJECTIVE:

The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability.

BACKGROUND:

Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown.

METHODS:

Casualties evacuated from POI to one level III facility in Afghanistan (July 2008-March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins.

RESULTS:

Most casualties (n = 1054; 61.2%) were in the low-ISS (1-15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16-50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51-75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality.

CONCLUSIONS:

This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.

EVASAN: Médicalisé, c'est mieux

Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom

Apodaca A et All., J Trauma Acute Care Surg. 2013;75: S157YS

BACKGROUND: The following three helicopter-based medical evacuation platforms operate in Southern Afghanistan: the US Army emergency medical technician (basic)Yled DUSTOFF, US Air Force paramedic-led PEDRO, and UK physician-led medical emergency response team (MERT). Nearly 90% of battlefield deaths occur in the prehospital phase, comparative outcomes for these en route care platforms are unknown. The objective of this investigation was to characterize the nature of injuries in patients transported by three evacuation platforms. In addition, it aimed to compare observed versus predicted mortality among these provider groups.

METHODS: A performance improvement study involving 975 coalition patients injured in Southern Afghanistan, transported from the point of injury to a military hospital, was performed. All patients were alive on admission with prehospital documentation recorded in the US Department of Defense Trauma Registry from June 2009 to June 2011. The main outcome measure was in-hospital mortality and observed versus predicted (Trauma and Injury Severity Score [TRISS]) survival were the primary end points.

RESULTS: MERT transported more amputation and polytrauma casualties and included patients with higher mean Injury Severity Score (ISS) compared with PEDRO and DUSTOFF (16 [13] vs. 11 [10] and 10 [10] respectively; p G 0.001). DUSTOFF was excluded from the subgroup analysis owing to insufficient numbers of severely injured casualties with only one death. The overall mortality for MERT and PEDRO was similar (4.2% vs. 4.6%, p= 0.967). Stratifying by ISS, there was lower mortality in MERT compared with PEDRO in the range of 20 to 29 (4.8% vs. 16.2%, p = 0.021). The observed mortality among PEDRO casualties was as predicted with the exception of the range of 20 to 29, while mortality in MERTwas lower than predicted for all ISS groups with greater than 10.

 

CONCLUSION: MERT achieves greater than predicted survival, which may be related to the additional capabilities onboard. This supports the adoption of a versatile medical evacuation system with scalable crew and equipment configurations that adapt to meet the medical, tactical, and operational needs of future conflicts.

La douleur: S'en occuper ACTIVEMENT

Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan

Buckenmaier III CC et All. Pain Med. 2009 Nov;10(8):1487-96.

Objective. Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. Painmanagement practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. An exploratory study was undertaken to examine pain and other outcomes during evacuation and at Landstuhl Regional Medical Center (LRMC), Germany. 

Design. A mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded U.S. soldiers evacuated from Iraq and Afghanistan to LRMC. Setting and Patients. A total of 110 wounded soldiers evacuated from Iraq and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0–10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann–Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.

Results. Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05).

Average percent pain relief achieved was 45.2%  26.6% during transport and 64.5%  23.5% while at LRMC (P < 0.001).

Participants with CPNB catheters placed at LRMC reported significantlyy less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs

Conclusions. Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes

Mieux on est formé, plus on fait

Army flight medic performance of paramedic level procedures: Indicated vs performed

Bier SA et all. - J Emerg Med. 2013 May;44(5):962-9.

Of 984 interventions found to be indicated on the 406 charts that met inclusion criteria, 36% were rated as EMT-P level. Seventeen percent were indicated but not performed. EMT-Bs failed to perform indicated procedures 35% of the time vs. 3% in the EMT-P group (p < 0.001). For paramedic-level procedures, EMTBs failed to make 76% of appropriate interventions, compared to <1% in the EMT-P group (p < 0.001). Conclusions: There seems to be a substantial number of procedures beyond the scope of standard Army flight medic training being required for Army AMT missions. It seems that when advance interventions are indicated, those trained to the EMT-P level perform them significantly more often than those trained to Army standard. Conclusions: Based on the findings of this study, the authors suggest the Army consider adopting the standards required for civilian AMT

Commentaire:Notez la part de pédiatrie

Commentaire: EMT-B = Auxilaire sanitaire. EMT P = Technicien de niveau plutôt infirmiers formés exclusivement à la gestion de soins critiques. Pas d'équivalence avec la vision française (entre infirmier anesthésiste/réa ?)

Ceci milite pour la présence dans les vecteurs d'EVASAN notamment aériens de personnels paramédicaux spécifiques habitués à la mise en oeuvre de standards de soins critiques