LAST UPDATE | 15 May

THE SURVIVAL AND long-term health of victims of road traffic collisions and other serious medical emergencies are being put at risk by limited pre-hospital medical treatment, experts have warned, with the government urged to take action.

The Journal has spoken to consultants and other experienced professionals working in pre-hospital medicine internationally who expressed serious concern at how Ireland’s emergency medical service has been allowed to lag behind the standard in other countries.

The office of Taoiseach Simon Harris has received data compiled by Dr William Passmore, an NHS consultant in emergency medicine and pre-hospital emergency medicine, setting out the case for an upskilled helicopter emergency medicine service (Hems) in Ireland for the thousands of people seriously injured each year in Ireland.

The Taoiseach was warned of “profound and systemic” failures in prehospital care, and told Irish people have potentially been “misled” about the quality of care delivered to critically ill and dying trauma patients before they reach hospital.

Passmore also raised the issue with Leo Varadkar, then Tánaiste, in 2022, in correspondence highlighting how a best practice Hems service could save people from preventable deaths and disabilities.

In the Britain, Northern Ireland and Australia, for example, specially trained doctors are routinely despatched by helicopter to serious incidents such as potentially fatal road traffic collisions. They can provide life-saving treatments at the scene before patients are brought to hospital. 

In the Republic of Ireland, such incidents are almost always attended by paramedics or advanced paramedics who cannot perform surgery, administer emergency anaesthetic or give blood transfusions, meaning vital time is lost before seriously injured patients are treated, even if paramedics travel by helicopter.

If doctors attend the scene of an incident in Ireland, they do so on a voluntary basis and can only provide a limited service – for instance they do not routinely carry blood and may not be able to provide an emergency anaesthetic.

Dr Lisa Cunningham is a consultant in emergency medicine at Mayo University Hospital and a pre-hospital physician with the Lincs & Notts Air Ambulance in the UK. She said she sees patients in Ireland who would “absolutely” have had a better chance of survival and long-term health had they received critical care at the scene.

“If someone is bleeding out, it’s an hour and a half before they can get blood [in the hospital]. It’s an hour and a half after their crash for airway control and basic oxygenation, proper management of the airway to prevent brain injury,” Cunningham said.

“We are seeing it all the time. I know we are missing people who have died at the scene or died enroute to us.”

Another consultant working in pre-hospital medicine overseas noted that of a group of 120 major trauma patients who needed airway management in Ireland in 2021, 72% were intubated in hospital and just 6% pre-hospital. 

“That’s something we would do on the roadside here,” said the consultant who is working overseas.

“These could be people who have preventable harm from brain injury. If they had proper services on the road that [anesthetic and intubation] could have been done by the roadside and probably prevented death and/or harm to patients.”

Administering anaesthetic helps to protect the brain from further injury after trauma. Paramedics cannot administer emergency general anaesthia. In the Welsh Hems, for example, an average of 66 emergency general anaesthetics for traumatic brain injuries are given each year.

“Every other country that has a physician-staffed Hems can’t be wrong,” the consultant said.

“It really is about putting the patient at the forefront of care and delivering gold standard care, which [Ireland] is not doing at the moment.”

A fourth consultant working in pre-hospital medicine overseas said: “It’s not about scooping somebody up and flying them very quickly to the hospital where the doctors are waiting. It’s about using the helicopter to insert the doctors right beside you at the roadside.”

The consultant noted that providing critical care at the roadside – effectively bringing the hospital to the patient – meant they could then be flown to the care centre they needed, such as a major trauma or neurosurgery centre, rather than diverting to a local hospital first for airway protection, emergency surgery or a blood transfusion.

“The air ambulance model of 30 years ago has changed drastically in the UK and actually all throughout the world – except for Ireland,” the consultant said.

“The reality is [the Irish National Ambulance Service] doesn’t have high performing clinicians who can perform life saving interventions on the side of the road. Helicopters don’t save people, it’s the crew on board.”

The consultants working overseas asked to remain anonymous for reasons to do with their work. 

The Central Statistics Office recorded 1,584 deaths from “external causes of injury and poisoning” in 2021 – with 60% of deaths among young people aged 15-34 attributable to such incidents.

Almost 5,000 cases of major trauma – through falls, assaults, sports injuries and road traffic collisions among other causes – were treated in Irish hospitals in 2021, according to the National Office of Clinical Audit’s most recent major trauma report. It does not record trauma patients who die before reaching hospital.

People who are still alive after suffering a traumatic injury have a stronger chance of surviving if they are treated immediately, with the term “golden hour” often used in emergency medicine to refer to the importance of rapid medical and surgical treatment to prevent death.

Longstanding issue

The need for physician-staffed Hems in Ireland has been raised before.

In 2018, the Irish Association for Emergency Medicine (IAEM) doctors’ organisation expressed concern that a new community-funded air ambulance in the south of Ireland would not be staffed by doctor-paramedic teams, but rather by advanced paramedics and emergency medical technicans.

The IAEM said these workers did not have the necessary skills – or scope of practice – to meet the emergency needs of the most seriously ill or severely injured. It noted that doctor-paramedic teams were “the accepted model of Hems staffing in the UK, mainland Europe and Australia”. Deploying doctor-paramedic teams was supported by a “significant body of scientific evidence showing optimal patient safety and clinical outcomes”.

The issue has been raised in the Dáil, including by Independent TD Cathal Berry, who noted last year that Northern Ireland had “fully kitted out Hems” staffed by doctors while in Wales there were “six fully dedicated helicopters and teams”.

Berry said Hems teams could offer “a lot of critical care at the point of impact in a road traffic accident” and this was a model Ireland needed to look at.

International comparison

All regions of the UK are covered by air ambulance services crewed by teams of doctors and paramedics, with doctors despatched to the most serious incidents.

Northern Ireland has had a physician-staffed Hems service since 2017.

Wales set up an an Emergency Medical Retrieval and Transfer Service in 2015, which provides pre-hospital critical care by consultants and critical care practitioners. The service is a partnership between NHS Wales, the Welsh government and the Welsh air ambulance charity.

A review of the first five years of the service’s operation found that 63% of patients received pre-hospital care that would not have been available from a standard ambulance crew. 

The review found the number of patients dying within 30 days from blunt trauma injuries (such as from falls, traffic collisions or crush injuries) was 37% lower than if they had been attended by an ambulance service only. It was suggested this could be due to both the timeliness of medical intervention at the scene, and the speed of transport to hospital, as both helicopters and vehicles are used by the service.

The service provided critical interventions to patients 29-41 minutes faster than was possible with a standard 999 response.

Like Ireland, Wales has a large rural population that is harder to serve with a traditional ambulance service. The review found the service had improved equity of care in North Wales, a predominantly rural area, more than doubling the attendance of doctors at critical incidents.

Doctors are also on standby to travel to emergency calls by road, helicopter or boat in Norway, which like Wales and Ireland has a large rural population – as a recent paper describing the service outlined.

A study by the European Transport Safety Council in 2019 highlighted the benefits of the “rendezvous” emergency medicine system spearheaded in Germany, and also used in Austria, Czechia and France, whereby a doctor is despatched in a separate vehicle to the ambulance. That means once the patient is stabilised, the doctor can attend another call while the patient is transported to hospital. 

The ETSC noted that in many European countries, specialist emergency doctors travelled to and from the scene. The ETSC is an umbrella body of which the Irish Road Safety Authority and Health and Safety Authority are member organisations.

Staffing

The Welsh service review found that the establishment of Hems had helped recruitment of 12 new consultants.

In 2018, the IAEM noted that Irish doctors who had completed Hems training and fellowships abroad were willing to work in the south of Ireland service, while other Irish Hems doctors were currently workign overseas and “may well be encouraged to return home and work in our hospitals wiht a part-time Hems clinical commitment”.

HSE responds

The Taoiseach’s office and the Department of Health were asked for comment. They referred the query to the HSE.

The HSE said the service in Ireland was based on “an internal evaluation of the needs of prehospital emergency care in Ireland”. It said the National Ambulance Service (NAS) tasked helicopters to 904 incidents last year.

The HSE said it aimed to “ensure seamless, efficient and optimal service provision for some of the most acutely ill and injured patients who are treated and transported by the NAS”.

It said that NAS provided two helicopter emergency medical services staffed by advanced paramedics, which “provide a lifesaving service, offering fast access to prehospital emergency care interventions at the roadside by highly trained emergency care personnel”.

It said the helicopters have “greatly reduced scene-to-hospital times in more rural parts of the country and can bring the patient to the hospital that best suits their life saving needs, not just the closest geographically”. 

It said the Coast Guard also provides support using its four helicopters when they are available. 

Volunteer emergency medical response

Emergency medical response charity Critical announced this week that a consultant in emergency medicine at University Hospital Kerry in Tralee had joined its volunteer team for the county.

Dr Herlo Coetzer will work with the National Ambulance Service and Critical’s volunteer paramedics and emergency medical technicians to attend to patients at scene when he can.

Critical currently has a network of 10 doctors and consultants in emergency medicine who volunteer to respond to serious and life-threatening incidents and illnesses in their areas, based in counties Waterford, Wicklow, Kerry, Mayo, Donegal and Dublin.