Helicopter Critical Care Retrieval in a Developing Country: A Trauma Case Series from Bhutan

Background

Decades of medical research and experience have shown that patients with critical illness and injury fare better when they receive timely emergency and critical care (Howard et al., 2018). There are benefits of early critical care for victims of trauma and also for patients with many critical medical conditions. Whether a patient's severe respiratory distress arises from heart failure, sepsis, and septic shock or traumatic injury, the patient is more likely to survive if critical care is provided before respiratory arrest occurs (Eastridge et al., 2012; Prasad et al., 2017; Seymour et al., 2017). In the developed world, the recognition that time is important in the treatment of severe injury and illness spurred the creation of emergency department and prehospital systems. Especially for victims of traumatic injuries, military experience has shown that care of the seriously injured requires an organized system to achieve the best outcomes.

In countries with adequate financial resources, robust infrastructure, and populations clustered in metropolitan areas, the initial solution was straightforward. Building on military experience, developed countries created emergency medical services (EMS) with technicians who were able to provide temporizing care while transporting patients to hospitals. Even with those systems in place, some locales took a second, more dramatic, step, establishing helicopter-deployed EMS (HEMS). Dispatch of specialist physicians, paramedics, and nurses to the patient by helicopter can reduce mortality (Dickinson et al., 1997; Timmerman et al., 2008; Galvagno et al., 2012; Apodaca et al., 2013; Goto et al., 2019). In the United Kingdom, the physician-led teams of London's Air Ambulance perform prehospital thoracotomy with an 18% survival rate for patients in cardiac arrest due to penetrating thoracic trauma (Davies and Lockey, 2011). By comparison, the average in-hospital survival rate for patients in traumatic cardiac arrest hovers around 7% (Rhee et al., 2000). In large countries such as Australia there is another benefit of helicopter-delivered critical care. With a sparse population, and far-flung small cities and villages, a ground ambulance can take hours or days to reach a patient in need of critical care that is only available in large cities.

Countries in the developing world share the challenge of providing timely medical care to trauma victims, while facing others such as a higher trauma burden, poor infrastructure, inadequate government resources, and a lack of technical expertise. These challenges can severely limit the provision of critical prehospital trauma care in the developing world.

Bhutan is a developing country that provides free health care to all its citizens as part of its celebrated dedication to “Gross National Happiness.” It maintains a robust network of outreach clinics, basic health units, and district hospitals, but similar to other nations with a large portion of the population living in rural communities, the ability to deliver emergency and critical care is limited by geography. In many small villages from the high eastern Himalayas to southern jungles, road access is difficult or completely lacking. Without road access providing timely emergency medicine and critical care is difficult to achieve. To meet this challenge, the Royal Government of Bhutan created an aeromedical critical care retrieval team, similar in concept to teams deployed in Japan, Australia, and Europe, with independent evidence-based triage, which provides critical care to its citizens at no personal cost. The team is financed through the pooling of public and private resources, with the emergency human resources roster of nurses and physicians provided free of cost by the Jigme Dorji Wangchuck National Referral Hospital, equipment provided free of cost by the charitable Bhutan Foundation, helicopter rental provided at reduced rates by the government-owned enterprise Royal Bhutan Helicopter Service Limited (RBHSL), and rental and overhead costs covered by the Emergency Medical Services Division, Ministry of Health, Royal Government of Bhutan. One retrieval flight with a duration of 60 minutes is charged at 150,940 BTN, or ∼2200 USD to the Ministry of Health.

Methods

The national emergency dispatch center of Bhutan (Health Help Center [HHC]) sends a critical care helicopter retrieval team to any patient who meets predetermined triage criteria. We performed a review of the records of the national emergency dispatch center of Bhutan (HHC) and of hospital records for all patients cared for by the Bhutan Emergency Aeromedical Retrieval (BEAR) team during its first 4 months of service and identified all trauma cases. For each patient, we then collected the patient's age and gender, the list of injuries, the mechanism of injury, the interventions by the critical care retrieval team, and patient outcome (alive vs. dead).

The protocol for this study was cleared by the Research Ethics Board of Health (REBH) of the Ministry of Health, Royal Government of Bhutan. A waiver of regulatory requirements for obtaining and documenting informed consent was obtained.

Results

During the first 4 months of service BEAR cared for 50 patients, of whom 16 were trauma patients. Fourteen patients survived to hospital discharge; two died after hospitalization. No patient died on scene or during transport. The team successfully treated several challenging casualties, including a patient gored by a water buffalo leading to traumatic cardiac arrest with successful resuscitation, victims of a compressed gas cylinder explosion, a bear mauling, and a penetrating arrow injury to the head. The team successfully performed a variety of critical care interventions, including induction and maintenance of anesthesia, orotracheal intubation, mechanical ventilation, tube thoracostomy, administration of blood products, and successful management of traumatic cardiac arrest (Table 1).

Discussion

This case series indicates that a low-income country such as Bhutan can organize and deploy a critical care HEMS team to meet the needs of severely injured patients who are located far from reliable emergency or critical care. Successful retrieval of these patients demands expertise in emergency and critical care medicine as demonstrated by the skills the team employed in the field. This was a preliminary study. We studied the first 4 months to determine the effectiveness of a critical care HEMS service in a low-resource setting with a view toward making improvements. We anticipate studying and reporting on a longer period, likely 2 years. We felt that the results were promising enough to share them now rather than waiting. We reported only trauma cases in this report because disease severity is more quantifiable, and prediction of outcomes is more straightforward for trauma than for general medical cases.

Before the establishment of HEMS evacuation, care for critical patients in remote communities in Bhutan was routinely provided by village health assistants with limited critical care training and equipment at their disposal. Patients who survive initial care in a rural clinic would be transported by basic life support ambulance or horseback for extensive periods to the nearest of the country's three referral hospitals. Bhutan's retrieval team provides timely care that patients would not otherwise receive. Although baseline data for comparison from the period before HEMS establishment is difficult to obtain, it is likely that the use of a critical care HEMS team has strongly reduced morbidity and mortality of critical patients. A different study design with a larger number of cases, a longer period of evaluation, and preferably collection of facility records from remote health facilities would be required to definitively demonstrate sustained mortality benefit. Organizational aspects of the BEAR team will be documented in a separate dedicated publication.

Conclusion

A critical care helicopter retrieval team can deliver trauma care in a developing country, such as Bhutan, with favorable patient outcomes at low cost.