The Emergency Medical Retrieval Service (EMRS) now forms part of the specialist transport and retrieval division (ScotSTAR) within the Scottish Ambulance Service. EMRS provides critical care to acutely ill and injured patients in remote and rural Scotland and transfers them either by ambulance, helicopter or plane.
EMRS is a consultant-led service, therefore affording patients the highest degree of critical care possible within the NHS. Each team comprises of two team members, the consultant and either a trainee registrar or critical care practitioner (CCP).
The service's CCPs are from either a paramedic or nursing background and have extensive experience in their respective fields prior to joining EMRS. The CCP role has many responsibilities and functions but the primary focus is to augment the critical care delivery led by the consultant to provide safe, robust and timely intensive level care to patients.
Retrievals are categorised as primary or secondary. Primary retrievals are those requiring the EMRS Trauma Team to provide critical care in the pre-hospital environment before transferring patients to definitive care. Secondary retrievals require the team to attend patients in remote or rural healthcare facilities. These facilities vary in size, staffing and capabilities. Patients at such locations who require HDU or ICU levels of treatment are stabilised and transferred by EMRS to larger metropolitan hospitals.
Background to postpartum haemorrhage
Postpartum haemorrhage (PPH) is the main cause of nearly 25% of maternal deaths worldwide (World Health Organization, 2012). The Royal College of Obstetricians and Gynaecologists (RCOG) categorise PPH into primary and secondary (RCOG, 2009).
Primary PPH is defined as a loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby (Mousa and Alfirevic, 2007). Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks after birth (Alexander et al, 2002).
PPH is categorised as minor and major:
Causes
There are four main classifications of causes of PPH often referred to as the four Ts. These are tissue, trauma, thrombin and tone (Ramanathan and Arulkumaran, 2006).
Of these four causes, uterine atony is the most common with retained placenta fragments or infection being frequent causes (Banks and Norris, 2005).
Treatment within UK Ambulance Services Clinical Practice Guidelines
UK Ambulance Services Clinical Practice Guidelines include the following advice regarding the treatment of PPH by ambulance clinicians (Association of Ambulance Chief Executives, 2013):
PPH in the remote and rural setting
Most pregnant woman in remote and rural Scotland will travel to deliver their baby in either a midwife-led unit at a rural general hospital or at a larger tertiary centre with obstetric, surgical and intensive care unit capabilities. However, as secondary PPH can occur up to 12 weeks post birth there is potential for these haemorrhagic emergencies to present in any of the remote and rural facilities EMRS provide a service to.
While EMRS do not routinely encounter patients with this type of aetiology, the service has systems in place to support both rural clinicians and patients with such a clinical presentation. EMRS has both an obstetric emergency standard operating procedure and a dedicated obstetric drug pack with which to treat patients suffering PPH. The service also has access to three units of packed red blood cells (PRBC) for use on primary and secondary missions along with a fluid warming system.
Clinical case
Phone call referral to the EMRS duty consultant during the night from island community hospital GP.
36 YOF Gravida 3 Para 3 who presented with slow but worsening onset of abdominal pain and persistent PV bleed. The patient was 16 days postpartum following the uncomplicated birth of her third child.
The referring centre was a GP-led facility with a local helicopter landing site (HLS). This was 40 minutes flight time from the EMRS base due to weather in a rotary wing aircraft. The local coastguard team assisted with the lighting and security of the HLS on the island as per the normal protocol.
Treatment at referring centre prior to EMRS arrival included:
Observations on EMRS arrival:
Pulse 107, BP 95/49, SpO2 99%, RR 14, GCS 15, Temp 37.6.
PV bleed still ongoing.
Treatment once EMRS on scene:
Issues:
Discussion
Challenges in the aeromedical retrieval environment
As with all patients who require rapid surgical intervention, there needs to be a balanced decision from the retrieval team as to how best to transport the patient. While these patients may need definitive surgery, transporting an unstable patient in the confined space of an aircraft can potentially have disastrous consequences. The aim of the rural clinician and the retrieval team should be to rapidly resuscitate and stabilise the PPH patient before safe, expeditious and direct referral to a consultant-led obstetrics unit.
Hypoxic patients secondary to hypovoleamia will see a 10% drop in their oxygen saturations once at an altitude of 10 000 feet (Martin, 2006). This can lead to reduced end organ perfusion, agitation and worsening coagulopathy. Robust and aggressive stabilisation of the PPH patient should be undertaken by the retrieval team prior to transfer. This should include optimised oxygenation, temperature control and volume replacement.
In the case of this patient, the effects of altitude were minimised, with low level rotary wing flight. Temperature control was maintained with thermal insulation and a vacuum mattress. Volume replacement was partially achieved with the blood products the team had with them. The patient was kept lying flat for the duration of the transfer.
Tranexamic acid
Tranexamic acid (TXA) works to prohibit fibrinolysis and consequently assists with the arresting of bleeding (Pinder and Dresner, 2005). In the UK it is a licensed drug for use in patients with a range of bleeding complications including those with high risk of pre- and post-operative bleeding, menorrhagia and haemophilia patients undergoing surgery (National Institute for Health and Care Excellence, 2012). The use of TXA in bleeding trauma patients has largely been supported by the results from a large-scale randomised control trial evaluating its use within a short period after the onset of injury (CRASH-2 trial collaborators, 2010). This along with subsequent analysis of the study's results shows TXA to have a positive effect on mortality levels in bleeding trauma patients when used within the first three hours (CRASH-2 trial collaborators, 2011).
TXA is not currently recommended by current UK guidelines for the treatment of PPH (RCOG, 2009). It is, however, used for other obstetric emergencies such as caesarean section. Recent evidence has suggested it is of benefit to bleeding trauma patients (CRASH-2 trial collaborators, 2010). Given this, it is understandable why the rural GP considered it prudent to administer TXA in this case of PPH.
The retrieval team elected not to continue with a TXA infusion as this is not current UK practice. Evidence in this area is varied (RCOG, 2009), but a large-scale international randomised control trial into the use of TXA in treating PPH patients is due to enroll its last patient in early 2016 (London School of Hygiene and Tropical Medicine, 2014). Once the results of this trial are published there will no doubt be a significant degree of interest in the discussion, conclusions and recommendations of the study's authors.
Considerations during treatment
The RCOG publish comprehensive guidelines on how PPH patients should be treated. Such guidelines are evidence based and considered best practice. For treatment of PPH the college set out four primary aims (RCOG, 2009), these are:
These four categories can apply to both ambulance clinicians and multidiscipline retrieval teams and should be important considerations when treating the PPH patient.
Communication
Early discussions with either the nearest obstetric unit or emergency department should prove invaluable. You may also be directed straight to a labour ward as opposed to the emergency department, potentially saving valuable time. Always inform the receiving unit of the fact you are bringing a patient with major obstetric haemorrhage.
Resuscitation
The patient's location and current clinical status will determine how much resuscitation they require. This may prove to be more complex in a remote and rural environment compared with a large urban area but the aims are the same. Correct any time-critical ABC issues within the remit of your training and organisation and expedite the patient to the nearest suitable hospital.
Investigations and monitoring
Again this will be impacted on by the location and circumstances of the patient and how serious the presentation of PPH is. A good history, patient assessment, continuous observations including SpO2, BP, pulse and ECG monitoring are essential. Monitoring the patient's temperature and keeping them warm is also crucial.
Arresting the bleeding
Mechanical and pharmacological methods are available to try and stop the bleeding:
Mechanical
Uterine massage may stimulate the uterus, stimulate contractions and assist with the arrest of any haemorrhage (Mukherjee and Arulkumaran, 2009).
Pharmacological
Misoprostol and syntocinon are the two common drugs used by ambulance clinicians to assist with the treatment of PPH. Both of these work to stimulate uterine smooth muscle and encourage uterine tone. This in turn aims to decrease PPH (Moore and Chandraharan, 2010).
Conclusions
Postpartum haemorrhage is one of the main causes of maternal deaths worldwide. The presentation of this aetiology in the remote and rural setting presents significant challenges to both referring and retrieval clinicians. A safe, timely and robust response to transferring these patients direct to definitive care is necessary.