Abstract
To the Editor:
We thank Soteras et al 1 for their interest in our recently published article on cardiac events in mountain rescues, 2 and we acknowledge their previous contribution in the field. 3 We are truly grateful for the opportunity to clarify certain points that could have been potentially misunderstood.
All of the patients diagnosed with an acute coronary syndrome in our study were adequately transferred to the hospital. When we asserted that 58% were transferred to the hospital in an advanced life support (ALS) staffed vehicle, helicopter emergency medical service (HEMS), or emergency medical service (EMS), we did not mean to imply that the other 42% were not transferred escorted by a medical team. In fact, these patients were transferred in the physician-staffed rescue helicopter according to the current operation procedures in Aragón (Spain). Risk assessment and prehospital triage was performed, and a 12-lead electrocardiogram was obtained in the first medical contact as recommended by the European Society of Cardiology guidelines. 4 Not a single patient was transferred to the hospital without an ALS provider. Thus, we consider our patients to have been properly treated, and certainly in accordance with all international guidelines.
In general terms, as Soteras et al 1 point out, rapid recognition of symptoms and on-site evaluation by an ALS team are factors that undoubtedly contribute to improve the global outcome and the survival chain. Therefore, we strongly endorse the call to include physicians in rescue teams and adhere to the opinion of many experts who support and promote the joint work of mountain rescue services and EMS.5,6 In the Spanish region of Aragón in particular, the standard operations system has successfully managed to integrate an ALS provider in all mountain rescue services for the last 2 decades. The following paragraphs explain how this system works in Aragón.
On one hand, there are search and rescue helicopters with no electromedical devices previously installed. These helicopters may carry a physician/nurse on call if needed, and their equipment is chosen according to the type of rescue (modular medical backpack with pharmacotherapy such as initial antiplatelet therapy, monitor-defibrillator, respiratory kit, or trauma kit). Health providers can medicalize the onsite assistance of the victim. The selection of the equipment carried is of paramount importance. It should be resistant, small, and modular for adequate performance. 7
On the other hand, there are ALS-staffed EMS (ambulances) and 1 ALS-staffed HEMS. They are staffed with both physician and nurse and permanent electromedical devices. They are not involved in search and rescue operations. In addition, they can provide adjunct fibrinolytic therapy to the initial pharmacotherapy when it is considered the best reperfusion strategy.
In mountain rescues, the most common procedure is to transfer the patient in a search and rescue helicopter with a physician/nurse to the nearest local hospital. Notwithstanding, in cardiac events (and other complex pathologies), the transfer of patients has been optimized through infarction code protocols to avoid any EMS delay; when needed, the transfer can proceed directly to the hub-reference hospital with hemodynamic services.
The transfer of patients, as a hub-and-spoke system, makes use of the most suitable resources available at the time of the event, considering external factors such as weather conditions and distances and evidently taking into account the best treatment strategy for each patient (primary percutaneous coronary intervention vs fibrinolytic therapy).
Finally, we would like to address the points made by Soteras et al 1 about new technologies. Undoubtedly, current technologies allowing electrocardiogram transmission or “second opinion” consultation aid in early diagnosis and reduce treatment time. Telemedicine ensures catheterization lab activation, eliminating any emergency department delay. 8 Hence, when related to point-of-care ultrasound (POCUS), tele-echocardiography may guide treatment. During cardiac arrest, POCUS demonstrated feasibility and high positive predictive value (97%) when assessed by physicians; however, when POCUS was performed by paramedics during pulse checks, it led to prolonged pauses in compressions. 9 In situations where high-quality compressions cannot be safely delivered (ongoing cardiopulmonary resuscitation in ambulance transport or difficult locations), the use of a mechanical device is a reasonable approach and may provide a useful adjunct to standard treatment. Yet mechanical chest compression devices showed no improvement in outcome. 10 Therefore, health providers involved in rescue operations may have to decide for themselves whether to carry these devices, considering their human resources and the potential extra load.
In any case, first responders’ actions have unquestionably been proven to significantly affect outcome. Thus, we encourage proper training for first responders and the creation of an integrated net of automated external defibrillators in remote locations (mountain huts or ski resorts). To improve the quality of the chain of survival in any location, time delays and patient outcomes should be periodically assessed.