As pre-hospital care charity Irish Community Rapid Response (ICRR) prepares to launch the Republic of Ireland’s first community-funded helicopter air ambulance service, James Paul Wallis examines calls for a doctor to fly on every mission
For the second time in recent years, an appeal has been made for an about-to-launch HEMS service on the island of Ireland to carry doctors on board, garnering widespread coverage in the local media. In September 2018, an open letter was submitted to Irish Taoiseach (Prime Minister) Leo Varadkar and Health Minister Simon Harris, calling for doctors to staff Ireland’s first community-funded emergency helicopter service. Signed by a number of doctors connected to air ambulance organisations around the world, the letter expressed concern that the National Ambulance Service was seeking to staff the service with an emergency medical technician (EMT) and advanced paramedic configuration. The letter claimed: “This is not up to the standard expected of a HEMS and will not be able to provide advanced prehospital medical and trauma care to the critically ill and injured patients it is tasked to. It will be not be a flying emergency department (ED) or intensive care unit (ICU).”
It’s not the first time that Ireland has seen an international call for doctors to be part of a new HEMS set-up ahead of its launch. Back in 2016, plans were being finalised for an air ambulance service covering neighbouring Northern Ireland, part of the UK. At that time, a similar letter was sent to Northern Ireland Minister of Health Michelle O’Neill appealing for Air Ambulance Northern Ireland (AANI) to carry doctors on its helicopters. AANI now operates with doctor/paramedic teams that deliver ‘critical advanced pre-hospital care’ to patients, but the service declined to comment for this article on the benefits of carrying doctors on board, or whether the geography and types of patients it deals with are similar to those likely to be handled by the new service in the Republic of Ireland.
It’s interesting to note that both letters state that ‘all of the UK’s 35 air ambulances are physician-staffed or are in advanced planning phase to move to that model’ (the 2016 letter omits the word ‘advanced’). Wiltshire Air Ambulance (WAA), however, is one UK service that currently flies with paramedics. Speaking to AirMed&Rescue in 2016, David Philpott, Chief Executive of WAA, then referred to staffing with doctors as a ‘platinum standard’ and ‘very expensive’. He also suggested, though, that the medical limitations of a paramedic-only service are rarely seen. And speaking to this publication recently, he said that WAA continues to operate with a clinical team that is predominantly critical care paramedic-led: “This suits our geography, funding limitations and the nature of the vast majority of medical and trauma incidents which we attend.”
However, Philpott added that a move towards a doctor-led service, ‘predominantly for the enhanced clinical training and supervision this supplies’, is highly desirable. The issue, though, remains one of cost versus benefit: “This is a complex and emotive matter of ‘health economics’ where the cost of saving a life is sometimes crudely quantified. External independent analysis of our mission profiles in 2012 and 2015 satisfied our Board of Trustees that the additional costs of employing doctors on each and every flight was not compelling enough to make the change. It always remains under review.”
Of course, funding for UK HEMS charities largely comes through public donations, so the question of what is affordable comes down, not least, to what the public will support. Of this, Philpott said: “There are limits to which the donating public will go in terms of the fundraising ‘ask’, and my judgment after nearly 20 years in the air ambulance business is that we may have reached the limits of that ‘ask’.”
The Association of Air Ambulances (AAA), a body representing UK HEMS charities, mentioned the Scotland Charity Air Ambulance alongside WAA as an example of a paramedic staffed service. A spokesperson told AirMed&Rescue: “A number of AAA members do not fly with doctors. This is a decision taken by the charity and one that is supported by the AAA. It is down to the size of the charity and ... the geography and patient types. Of course, funding is also a matter to consider.”
Similarly to the open letters, the Irish Association for Emergency Medicine (IAEM) argued in a statement in September that staffing HEMS with doctors is the accepted model not only in the UK, but also in mainland Europe and Australia. Although, as we’ve seen, it’s not the case across the whole UK, there are indeed some countries where HEMS means doctors. As an example, Poland’s state air rescue service, Lotnicze Pogotwie Ratunkowe, told AirMed&Rescue that its crews always comprise a paramedic and doctor.
Likewise in Norway, the standard is one HCM (HEMS crew member) and one doctor, explained Dr Per Bredmose, a Consultant in Prehospital Care and Retrieval Medicine working in Norway, who was among the signatories of the letter issued in 2016. In his opinion, the patients likely to be seen in Ireland are comparable to those in Norway. He added: “I truly believe that there should be a physician on board. HEMS is rarely about the transport vehicle, but about delivering competencies to the patient. I also truly believe that in order to utilise the resources in the best possible way, that HEMS with physicians on board shall be tasked to both trauma and medical jobs.”
Dr Hervé Coadou, an Emergency Physician with UF SMUR Héliporté SAMU59, France, was among the signatories of the latest letter. He explained that all HéliSMUR (HEMS teams) in France are physician-staffed. In his opinion, it would be nonsensical for these helicopters to fly without an emergency physician. He told AirMed&Rescue: “We consider prehospital activity as a part of hospitals. The French concept is ‘hospital ICU teams going outside hospital’.”
On the other hand, doctors are not the norm worldwide. Roylen ‘Griff’ Griffin and Eileen Frazer, Executive Directors of accrediting bodies NAAMTA (National Accreditation Alliance Medical Transport Applications) and CAMTS (Commission on Accreditation of Medical Transport Systems) respectively, commented that most services in the US do not use physicians onboard their aircraft. A spokesperson for New Zealand’s Philips Search and Rescue Trust, meanwhile, said that the region it covers (Central and Lower North Island) uses a mixture of paramedics and doctors, adding: “The vast majority of our work is, however, undertaken without a doctor and medical care and treatment is provided via an intensive care paramedic and an additional medically qualified person (paramedic/EMT) onboard.”
Contrary to what might be understood from IAEM’s statement, there are even Australian HEMS providers that don’t routinely fly doctors. Ambulance Victoria, for one, has staffed its helicopters with intensive care flight paramedics for primary response for more than 30 years, with ‘excellent patient outcomes’, according to Anthony De Wit, Manager of Air Operations. He added that this staffing can change for time-critical transfers between hospitals to include a specialist doctor from a retrieval service working alongside the flight paramedic. However, he said: “Doctors are not routinely responded to what we term as primary response requests (motor vehicle accidents, major trauma, heart attacks, etc.). The education, training and skillset of our intensive care flight paramedics is extensive and we have found that this system works exceptionally well as part of Victoria’s State Trauma System.”
Does it make sense to model the new Irish HEMS service on organisations elsewhere? In a statement addressing the recent letter, president of the Irish College of Paramedics Shane Knox asserted: “Comparison to Australia where helicopters are staffed by doctors is an ‘oranges and apples’ comparison.” He also said: “We have been served well over the last six years with the EMT/Advanced Paramedic model of HEMS provided by the Air Corps and the National Ambulance Service and there has been no identified need to change this model or evidence to suggest it is not working.” Knox recognised that a physician could make a ‘greater impact’ on trauma missions, but added that only a minority of emergency calls in Ireland relate to trauma.
In response, Dr Brian Burns, a signatory of both letters who is from Ireland originally but now works in Australia, told AirMed&Rescue: “Ireland is like any other country in Europe in terms of trauma incidence, severity and type. HEMS are only tasked to the most critically ill or injured patients. They make up a small percentage overall of the total emergency calls an ambulance service receives. These patients, however, stand to gain the most by bringing the full suite of critical care interventions and skills to them rapidly at the roadside. This will save lives and decrease long-term morbidity.” Out of interest, AANI said in September 2018 that half of its taskings since its launch in July 2017 have been for road traffic collisions.
There is also the hybrid option of having doctors involved in missions, but not on board. For example, STARS of Canada has physicians on only around six per cent of missions, Mark Oddan, Senior Communications Advisor, told AirMed&Rescue. He explained, though, that STARS’s transport physicians have oversight on every call: “STARS physicians are available 24/7 to provide patient care and medical expertise for all missions. However, physicians do not necessarily need to fly to provide this care. They are able to work with experienced STARS air medical crew (nurses and paramedics) and utilise the medical equipment on board to get information and guide care. They guide medical care by phone and radio to the [crew] as they fly to the patient, assess the patient, and provide the best medical care possible to the patient as they make their way to the hospital.”
Availability of doctors
Could it come down to whether there are any doctors available? The IAEM alluded to a ‘national shortage of hospital consultants’. The Irish Times reported John Kearney of ICRR as saying that it would be difficult to assign doctors to be on standby for helicopter missions given the shortage of doctors in hospitals. However, Dr Burns told AirMed&Rescue he doesn’t subscribe to that theory: “To staff the helicopter in daylight hours needs one doctor a day, seven days a week. That’s four full-time equivalent positions. What’s more, in several parts of the UK, linked jobs in prehospital care with HEMS and in the hospital have been successfully done to attract specialist doctors to poorly staffed hospitals.”
The recent letter suggested that given the opportunity to work on the new service, Irish doctors working abroad might return. Likewise, the IAEM stated that overseas Irish emergency medicine and critical care consultants ‘may well be encouraged to return home and work in our hospitals with a part-time HEMS clinical commitment’.
Dr Burns concurred: “There are many motivated Irish doctors in emergency medicine and critical care in specialty training or already at consultant level working in major trauma centres in countries with mature trauma systems. They are also helping to develop and improve those systems they are operating in. They are also privileged, like me, to work with world-class prehospital services such as Sydney HEMS. Many of these doctors want to bring those skills back to the critically ill and injured patients of Ireland. Precluding doctors bringing these skills and expertise to HEMS would essentially greatly decrease the chances of them wishing to return. I personally would consider bringing those skills and systems knowledge back to Ireland.”
Taking a step back, it is of course great news that Ireland is to benefit from increased HEMS coverage. To quote from the latest open letter, ‘the population of Ireland deserves a world-class trauma system, underpinned by a world-class HEMS’. The question, of course, is what constitutes ‘world-class’.