They have experienced the Covid outbreak in Germany, and have also helped evacuating patients from the north of Italy.
These video interviews are with colleagues around the world. A sort of pulse check on what is going on in the Covid pandemic. How it is handled, and the experiences that are made so far.
Professor Matthias Helm and Dr. Björn Hossfeld are working in the Bundeswehrkrankenhaus Ulm, Germany. Helm is head of the Department of Anesthesia, Intensive Care and Emergency Medicine and Pain Care in the federal military hospital in Ulm.
Hossfeld is one of Helms co-workers, and responsible for the Department of Emergency Medicine.
This interview takes place in the middle of May. They are interviewed by Stephen Sollid, Medical Director in Norwegian Air Ambulance Foundation (NAAF).
Military hospital and HEMS
– In the pre-hospital setting we run two ambulances and one intensive mobile care unit, as well as the helicopter emergency medical services (HEMS) here in Ulm, Helm tells.
Helm explains that their system is a bit different from other countries:
– We are a military hospital.
Helm is also professor of anesthesia at the University of Ulm.
– The hospital is totally integrated into the civilian health care system, although we are a military hospital, 80 percent of the patients are civilians.
The hospital has around 500 beds, and functions as a level 1 trauma center.
– We have all facilities except heart surgery, pediatrics and obstetrics, but we do have all the specialties.
By profession they are anesthesiologists and intensivists.
– But from passion we are emergency physicians! We are the crazy people who take care in the field of emergency medicine, both in a pre-hospital and in-hospital setting.
1500 HEMS missions a year
The teams are rotating between the different departments, so they spend about 20 percent of their worktime in a pre-hospital setting.
– The rescue helicopter has about 1500 missions a year, and 95-97 percent are primary rescue missions. 40-45 percent are trauma missions, Helm tells.
In the area they have had more trauma missions after the Covid-crisis, a bit to the contrary to the experiences in other countries.
– The traffic is low, so the motorcyclists have free roads, so they use high speed. Nearly every day we have a severe, multiple blunt trauma motorcycle accident.
They have registered a 20 percent increase compared to last year.
– That is different from the experiences in Norway and Italy, where we see that the number of missions has gone down, and we see less trauma and medical patients, Sollid says.
– We are not sure why we have an increase, but the weather has been nice, and that can lead to an increase. But we don’t have any work accidents, Helm replies.
Handling of the Covid outbreak
– What is the situation in general in Germany now? Has the number of infected decreased?
– That’s right, at the moment there are low numbers of new infections. We only have two patients in the ICU that are intubated and ventilated, and about five others with confirmed Covid. So, the number is very low, both in our region and the surrounding hospitals.
Helm tells that Germany has 30.000 ICU-beds.
– At the moment I think the actual number is 1300 patients in the ICU, and 1/3 are intubated and ventilated. So, at the moment we are in a very good situation.
– You have helped taking patients from Italy?
– Yes, two months ago when the crisis started, our neighbors had some hot spots, for example Bergamo in Italy and Strasbourg in France. They asked us to take over patients. So, we did.
A take home message from Germany is that it is in advantage to have enough ICU-beds. They haven’t experienced problems with the capacity like other countries.
– The message is to refer the right patient, at the right time to the right hospital, with the right vehicle or helicopter or fixed wing.
– Italy was forced to transfer patients in a very severe condition, no one would transfer these patients in this condition.
(Note: If it was not absolutely necessary.)
Fixed wing transfer
The Germans chose to transfer the Italian patients by fixed wing. They used military big size planes with the capacity of up to six ICU-patients.
– We did four flights, with six patients on each flight. All patients were intubated. Their condition was very bad. I am not accusing my Italian colleagues, I am sure they did the best they could, but they ran out of their facilities and equipment. We received some patients at the airport that were ventilated with normal emergency ventilators. Those ventilators are not capable of treating Covid-patients, Hossfeld tells.
They had ICU ventilators on the flight.
– In the end we saw improvements on some patients during the flight from Italy to Germany, and the flight was 70 minutes or so.
Helm’s second take home message is that it might be easier to transfer these patients by helicopter if the distances are not that long.
– The distances from the northern parts of Italy and the eastern part of France to the southern part of Germany are short. Now we had to transport the patients with ambulances to and from the airport, receive the patient on the airport, disconnect the ventilator, and the ventilators in the ambulances are not always that good, and then we have to repeat the same in Germany. You have to think whether it is better to take the patients by helicopter – if you have the capacity. They can land at the referring hospital and the admitting hospital.
– We have the same discussion in Norway, Sollid confirms.
In Germany they have established a national ICU-registry during the Covid crisis, that can be compared to the trauma registry. With this system everybody knows which hospitals that are capable of taking Covid-patients and ECMO.
– We try to install a national evacuation center, so we won’t need to coordinate this between the different states. For example, if there is a problem with capacity in the south or in the north. We try to install it now, at the moment we don’t need it, but maybe in the future.
– To go back to HEMS: How did you prepare? At some point in January, February or March – you must have realized that something big is coming?
– A big advantage in our system, is that the same physicians are working in the hospital and on the helicopter. It is a small group with only seven paramedics and 20 physicians. They are all members of the Department of Anesthesiology. They work together in the OR, Emergency Department and the helicopter. So, it was easy for us to do the same changes in personal protective equipment (PPE) inside and outside the hospital setting, Hossfeld says.
They also changed some procedures on anesthesia induction and modified RCI (rapid sequence intubation).
– You have a well established team that are easy to train. What is your approach, since you mostly have primary missions, do you transport Covid-patients?
– If we know the patient is Covid positive or the suspicion is high, we try to use the ground, just because it is easier to clean the ambulance than to clean the helicopter after the mission. Then we don’t have the helicopter ready for other missions for two hours.
Instead they have introduced a second ICU-mobile ambulance in Ulm.
– Do you use EpiShuttle or wrap the patient up?
– We don’t use EpiShuttle or any other type of incubators. If we have to transfer by helicopter we would prefer to intubate, otherwise we use the safety equipment like FFP-mask, face shield and double gloves. It works very well.
They also try to expose less of the personnel to the patients in the pre-hospital setting. The team is in front of the door, only the physician enters. Only if it is necessary to do CPR the whole team enters.
Change in mindset?
– What about the future? Do you expect a second wave after the summer?
– We don’t know! Nobody knows what will happen, but we have to be prepared, of course. We do elective surgery, and at the moment we run about 70-80 percent of our OR’s. We are able to change immediately from a normal setting to an emergency setting both in the pre-hospital and in-hospital setting. It is no problem. We have been doing this for 2-3 months now, so we have to go back to normal, but if necessary we change again to emergency mode, Helm says.
– Do you think the Covid-crisis will change the service? In Norway we see a higher awareness of infectious diseases. Will it be a change of mindset?
– We see a change in mindset, but I do not believe that this will be a long-lasting thing, Hossfeld says.
They saw a change of mindset after the terror attacks in Paris in 2015. The awareness of terror, explosives and scene safety rose.
– This is already gone. It will be the same with infectious diseases. I do not believe we will have the same mindset 12 months from now.
– Thank you! It is interesting to see the differences and also similarities on how this has been handled. Any last takes from you to other countries and other services?
– I think the idea of a HEMS-forum that you have created is great. We should try to keep this forum even after the crisis. Congratulations, it is excellent! It is a very good idea and I think we have to keep it up, both Helm and Hossfeld ends the interview.
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