In many aspects of trauma care, the UK follows where the US has historically led, most notably in the establishment of organised inclusive systems of trauma care. However, one area where the UK leads is in the willingness and ability to put trauma physicians out in the field thus taking the trauma bay to the patient and driving forward innovation in prehospital resuscitation.
Helicopter Emergency Medical Services (HEMS) exist all over the UK. Each is its own charity staffed by NHS-employed doctors and paramedics, but essentially relying on public donations to maintain operational capability. London HEMS (also commonly known as London’s Air Ambulance) is unique in that it is only dispatched to time-critical major trauma incidents unlike other services which also respond to medical emergencies. Dispatch criteria include road traffic collisions with confirmed fatalities, person(s) hit by a train (common enough on the London subway network) or any other cause of traumatic cardiac arrest. The team consists of a specially-trained advanced paramedic and a senior trauma physician (typically an ED doctor, anaesthesiologist or surgeon coming towards the end of residency). Able to reach any location in London within 10 minutes of dispatch, the team is capable of delivering a variety of on-scene interventions including rapid sequence induction for endotracheal intubation, thoracotomy, blood transfusions, administering tranexamic acid and in recent years prehospital REBOA. London HEMS performed their first successful prehospital thoracotomy outside an Indian restaurant on Christmas Eve 1993. Since then a 15-year study of over 70 cases has shown an 18% survival rate for patients who were effectively dead on scene (with 85% of survivors reporting a good neurological outcome). The British philosophy is firmly that damage control trauma care starts in the field.
Yet stateside of the Atlantic the pendulum still remains tilted towards ‘scoop and run’ rather than ‘stay and play’ and the idea of doctors performing heart surgery or REBOA guided by flashlights and beneath a subway train somehow doesn’t seem as appealing. This despite the fact that the world’s first successful prehospital thoracotomy was actually performed in Houston in 1988. Helicopters in the US still typically serve a predominately medivac/retrieval role rather than one of actually delivering hospital-standard trauma care to the patient. But what are the reasons for this? Is it due to the increased threat of litigation and associated indemnity issues? Is it that residency program directors or hospital bosses are reluctant to allow clinicians to take time off from their day jobs to fly around in orange jumpsuits? Or is it just a different medical culture- believe it or not US doctors typically enjoy a more pampered and revered life than their European counterparts, so perhaps it’s just not the done thing to be throwing them out into the cold and rain.
The National Association of EMS Physicians (NAEMSP) website currently lists a number of ACGME-accredited EMS fellowships across 29 states which offer hands-on prehospital experience to Emergency Medicine residency graduates. These year-long programs are typically designed to provide EM physicians with a shop-floor understanding of the EM services they hope to one day lead as medical directors. They are not, however, tailor-made to ensure applicants receive an intense 6 to 12 months of helicopter-based advanced trauma care experience.
London continues to lead the field of prehospital trauma research and innovation, from performing the world’s first successful prehospital REBOA in 2014, to the recent introduction of red blood cell/plasma composites and previous trials of devices such as the Infrascanner for detecting intracranial haemorrhage. Future trials of new devices and pharmacological adjuncts are to be expected including prehospital ECMO (although our Parisian cousins seem to be leading the field in that respect).
Modern communications and social media have broken down logistical barriers and dramatically reduced the time it takes for new knowledge and ideas to disseminate and sink in. Opinions are shaped via visual abstracts posted on Twitter just as much as they are at major international conferences. It used to be normal to fill every bleeding patient with 2 litres of crystalloid (in some places it still is), but medical cultures change and adapt with the times and perhaps as growing European evidence continues to emerge of the merits of delivering high level trauma care to the patient at scene, we may see a culture shift in how prehospital trauma care is viewed in the US. Who knows, maybe someday we’ll see a survival rate of 18% for penetrating cardiac injuries in the US instead of the dismal 3% to 5% we currently see.
Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.