Introducing HARU - Saving the lives of seriously injured patients

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Based in Brisbane and the Gold Coast, Queensland Ambulance Service’s (QAS) High Acuity Response Units (HARUs) are staffed by critical care paramedics using techniques and therapies pioneered by battlefield medics. Queensland Ambulance Service Medical Director, Professor Stephen Rashford discusses HARU and how it fits with QAS’ commitment to providing the highest possible level of care to seriously injured patients.

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HARU paramedics provide advanced interventions over and above the standard critical care paramedic (CCP) scope of practice.
“The only good thing about wars is that they result in medical innovation,” Dr Rashford says. And this is where a lot of work has been done with the acutely bleeding patient. Trauma research tends to focus on the head-injured patient, which is obviously very important to us, but where the HARUs are making a huge difference is with that very small group of people who are bleeding to death,” he explains.
“If you made it to hospital with vital signs, you had a 98 percent chance of survival in some of the medical units in Afghanistan. And HARU transfers some of these principles to the civilian arena like cutting edge procedures from a technical perspective but most importantly, the quality assurance programs which are second to none in the military,” he says.
He adds, “HARU is a patient-centric initiative providing a seamless approach for people with the most severe traumatic injuries from the time of the injury to when they receive hospital care and beyond,” he explains.
“These paramedics provide care at a level seen nowhere else in Australia, and this is supported by extensive training and very strong clinical oversight by senior trauma physicians.”
“Several therapies used by the HARU team were developed in conflict areas in Afghanistan and they have been shown to have great value for patients with traumatic injuries. Trauma injuries represent a significant cost burden to the community and this very valuable intervention speeds the time it takes to get a person with traumatic injuries to definitive care, which improves their chances of recovery,” he says.
According to Dr Rashford, the techniques used by HARU include being able to administer general anaesthesia before a patient reaches hospital and to conduct surgical procedures on the chest cavity to relieve the buildup of blood or air under pressure.
He explains, “Paramedics are also trained to use ultrasound to identify critical internal bleeding, and this information can be quickly relayed back to doctors at the hospital to enable them to be better prepared when the patient arrives.” He adds, “Often, our patients are taken from the roadside directly into the operating room, bypassing the emergency department and saving crucial minutes, ultimately saving lives.”

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“The only good thing about wars is that they result in medical innovation.”

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Recently, the HARU team diagnosed a cardiac injury using ultrasound after a tradesman had a nail gun injury to his heart. Following direct transfer to the operating room, the man promptly underwent lifesaving heart surgery and was ultimately discharged from hospital only five days after arrival.
For those patients suffering critical bleeding, the HARU paramedics can administer blood transfusions en route to hospital. Dr Rashford noted that “The QAS has been at the forefront of aggressive blood transfusion therapy within urban environments, using minimal saline and maximising the early use of blood products. We are the only jurisdiction in Australia where this is readily available.”
“The officers who join the HARU team are already very experienced paramedics,” he explaines, adding, “They are Critical Care Paramedics with at least five years’ experience, but most of them have 10-15 years of experience.”
To illustrate HARU paramedic’s effectiveness in the field, Dr Stephen presents this critical care case study.
A 30-year-old male is struck by a car, lying on the road and extremely agitated. When HARU and CCP units arrive on scene the advanced care paramedic (ACP) crew is in the midst of placing an intravenous line into the highly agitated patient while a Queensland Fire and Emergency Services officer supports his spine.
The initial primary survey revealed the following:

• Airway – intact, cervical spine supported by manual midline immobilisation.


• Breathing – respiratory rate 28/min, equal expansion, no chest crepitus, no subcutaneous emphysema.


• Circulation – palpable radial pulse, heart rate 70/ min, soft abdomen, pelvis well-aligned and no significant external blood loss.


• Disability – GCS 9 (M4), significant agitation, boggy haematoma to right occiput, blood from right ear, blood sugar level 7.7 mmol/l and moving all limbs.


• Exposure – open right tibia/fibula fracture with significant exposure of displaced tibia.

The initial plan was to sedate the patient with ketamine to facilitate extrication to the ambulance, where a rapid sequence intubation (RSI – drug assisted intubation) would occur. The CCP undertook procedural sedation, using 10mg aliquots of ketamine to settle the patient. A total of 50mg of ketamine was administered.
Following completion of the RSI checklist, a further 100mg ketamine and 100mg Rocuronium (muscle paralysis) was administered and the patient was intubated on first pass. No hypoxia or hypotension resulted. An orogastric tube was inserted and a heating blanket applied, with the patient then departing scene for hospital.
Audit findings
The scene flowed well because of excellent teamwork by ACP, CCP and HARU officers. The patient arrived in hospital 34 minutes post the Triple Zero (000) call, fully packaged allowing immediate transfer to the CT scan and reducing time to identification of critical injuries. Each officer contributed to excellent team work.
A pre-hospital ultrasound was not performed due to the relatively short scene time and haemodynamic stability. It was reinforced that such a scan should still be done, often undertaken whilst other procedures, such as limb splinting is being done. Although it was acknowledged the individual officer workload was intense.
Discussion regarding the option of titrated ketamine (10mg) versus a single 0.5mg/kg dose was debated at length in the audit. The HARU officer felt the small titrated dose allowed for observation of the haemodynamic and neurological response. This is especially important in the setting of potential significant blood loss. Despite ketamine usually resulting in a good haemodynamic response, when the patient has profound blood loss this effect is compromised.
Learnings
Each paramedic contributes to the outcome, no matter what clinical level. Appropriate task allocation and working in parallel optimises patient care and scene time. The paramedics attempt to think five to ten minutes ahead, to plan interventions proactively and not be reactive (e.g. ultrasound). Ketamine is a great pre-hospital drug but has limitations in certain circumstances.

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“Trauma injuries represent a significant cost burden to the community and this very valuable intervention speeds the time it takes to get a person with traumatic injuries to definitive care, which improves their chances of recovery.”

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Professor Steve Rashford
Professor Steve Rashford is a specialist emergency physician and medical director for the Queensland Ambulance Service. He has 25 years experience in major trauma resuscitation, including developing innovative prehospital techniques in anaesthesia, ultrasound, blood transfusion and surgical approaches to complex chest injuries.