Aeromedical Program Research Articles

Operational implementation and lessons learned from Haiti's first helicopter air ambulance

Critical-care helicopter transport has demonstrated improvements in morbidity and mortality to those patients who utilise the service, but this has largely excluded developing country populations due to set up costs. Haiti Air Ambulance is the first completely publicly-available helicopter ambulance service in a developing country. US standards were adopted for both aviation and aeromedical care in Haiti due to proximity and relationships. In order to implement properly, standards for aviation, critical care, and insurance reimbursement had to be put in place with local authorities. Haiti Air Ambulance worked with the Ministry of Health to author standards for medical procedures, medication usage, and staff training for aeromedical programs in the country.Utilisation criteria for the helicopter were drafted, edited, and constantly updated to ensure the program adapted to the clinical situation while maintaining US standard of care. During the first year, 76 patients were transferred; 13 of whom were children and 3 pregnant women. Three patients were intubated and two required bi-level mask ventilation. Traumatic injury and non-emergency interfacility transfers were the two most common indications for service. More than half of the transfers (54%) originated at one of six hospitals, mostly as a result of highly-involved staff. The program was limited by weather and the lack of weather reporting, radar, visual flight recognition, thus also causing an inability to fly at night. In partnership with the government and other non-governmental organisations, we seek to implement a more robust pre-hospital system in Haiti over the next 12–24 months, including more scene call capabilities.

Emergency airway management in critically injured patients: A survey of U.S. aero-medical transport programs

Objective Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs. Methods The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail. Results 89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times. Conclusions The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.

Ketamine for prehospital use: new look at an old drug

Introduction Ketamine has been used extensively for analgesia and anesthesia in many situations, including disaster surgery where extra personnel and advanced monitoring are not available. There are many features of ketamine that seem to make it an ideal drug for prehospital use. The reported use of ketamine in the prehospital environment is limited, however. The purpose of this study is to review the experience in the use of ketamine in a regional air ambulance service and suggest indications for its use in the prehospital setting. Methods This was a retrospective study of all patients transported by a regional aeromedical program. Patients were included in this study if the crew had used ketamine at any time during the flight. Data regarding the transport collected included patient age, type of transport, indications for ketamine use, and adverse reactions. Results During the period studied, ketamine was used in 40 patients. The age range was 2 months to 75 years. The indications and situations requiring use were varied and included both trauma and medical patients. Hypotension with need for analgesia, agitation or combativeness and intact airway, or pain unresponsive to narcotic medications were the most common indications for use. Ketamine was used both intravenous and intramuscular, even without intravenous access. There were no adverse reactions. Conclusions Ketamine is an ideal drug for use in many prehospital situations. Our experience suggests that it is safe, effective, and may be more appropriate than drugs currently used by prehospital providers.

The esophageal detector bulb in the aeromedical setting

To determine the accuracy of the Esophageal Detector Bulb (EDB) in the aeromedical setting, we conducted a prospective, observational study of all intubated patients transported by an aeromedical program over two years. Flight personnel recorded the results of the EDB, clinical examination, pulse oximetry, and capnography (ETCO 2). Endotracheal tube position was confirmed by prehospital ETCO 2 or by the receiving emergency physician. There were 104 EDB assessments in 53 patients. The EDB correctly identified four of five esophageal intubations and 96 of 99 tracheal intubations. The sensitivity and specificity of the EDB in the detection of an esophageal intubation were 80% (95% CI, 38–96%) and 97% (95% CI, 92–99%), respectively, and the overall accuracy was 96% (95% CI, 90–98%). The EDB augments the ability of an aeromedical crew to determine endotracheal tube position, but its results must be carefully interpreted in the context of other available means of confirmation of endotracheal tube position.

E FFECTS OF A C ONTINUOUS Q UALITY I MPROVEMENT P ROGRAM ON H ELICOPTER L IFTOFF T IMES

Background. The continuous quality improvement (CQI) process addresses concerns from a systems approach, employing committees of employees rather than selected management personnel to identify and solve problems, improve patient care and efficiency, and enhance customer satisfaction. Little is known about the effects of the CQI process on an aeromedical program. Objectives. To create a CQI program within an aeromedical program and to investigate its effect on helicopter liftoff times for scene responses. Methods. A CQI program was established at a busy aeromedical service that completed 897 missions in the previous year. A concern identified by the CQI committee was delays in helicopter liftoff time after receipt of mission requests for scene responses. Each component necessary for liftoff (dispatch, pilot weather check, and crew response) was identified, time limits were set for each, new procedures were developed, and all staff received training on the new procedures. Computer tracking of each of the identified component times allowed comparison of data pre and post procedure implementation of the CQI-developed procedures. Results. After CQI changes in procedures were implemented, there were a total of 30 delays out of 323 calls (9% of liftoffs for on-scene flights). This represents a 6% reduction in total delays. The largest drop in component times was observed in crew response (2.6%). An unanticipated 10% drop in response times for interhospital liftoffs also occurred, presumably due to heightened awareness of the service to response times in general. Conclusions. These findings suggest that employing a program utilizing CQI concepts can shorten helicopter liftoff times and improve response times in aeromedical programs.

Army Aeromedical Crash Rates

Safety is a principal concern for everyone in aviation, including those in military and civilian aeromedical programs. The U.S. Army flies thousands of helicopter missions each year, including many aeromedical flights. The comparison between Army general and aeromedical aviation crash data provides a benchmark for establishing patterns in aeromedical safety and may be useful for similar programs examining safety profiles. To determine the crash rates of Army aeromedical rotary-wing (helicopter) programs and compare them with crash rates in Army general aviation. Retrospective review of safety data from 1987 to 1995. Crashes or mishaps are categorized into three classes: A, B, and C. Class A reflects the most serious mishap and involves loss of life or aircraft destruction, whereas classes B and C represent lesser but still significant mishaps. Crash rates are compared on a year-by-year basis and are reported as events per 100,000 flight hours. Statistical analysis was performed by the z test with Yates' correction, with significance set at p < or = 0.05. During the study period, 13.31 million total flight hours were recorded, with 741,000 aeromedical hours logged. The mean Army general aviation class A crash rate was 1.86 compared with the aeromedical rate of 2.02. The mean general class A to C crash rate was 7.37 compared with the aeromedical rate of 7.44. Between 1992 and 1995, there were 3 years when the Army aeromedical program suffered no class A mishaps. Differences between study groups are statistically significant, but they are interpreted conservatively given the very low incidence of mishaps in both groups. Both rates are comparable with published civilian mishap rates. There is a very low overall incidence of crashes in both groups. There may be no practical difference between Army general and aeromedical aviation mishap rates. Furthermore, Army crash rates are comparable with published civilian mishap rates.

Prehospital fentanyl analgesia in airtransported pediatric trauma patients

Objective: To review the 5.5-year safety record of a protocol guiding fentanyl administration to pediatric trauma patients undergoing aeromedical transport. Methods: Retrospective review of an urban aeromedical program's trauma scene responses from October 1991 to March 1997 identified the study population as all pediatric patients (age <15 years) receiving fentanyl for analgesia during air transport. Patients receiving fentanyl concurrently with other agents, eg, paralytics, were not studied. The air transport team consisted of a flight nurse and flight paramedic who provided protocol-driven patient care with off-line medical control. Study patients' flight records were reviewed to determine vital signs (systolic blood pressure [SBP], heart rate [HR], and oxygen saturation [SAT]) before and after fentanyl administration. Postfentanyl vital signs were reviewed for evidence of hemodynamic or ventilatory compromise. Pre- and postfentanyl vital signs were compared with the paired t test (P < 0.05). Flight records were also analyzed for narrative information, eg, naloxone administration and assisted ventilation, indicative of fentanyl side effects. Results: Fentanyl (0.33-5.0 μg/kg) was administered 211 times to 131 patients who had a median age of 6.2 years (0.1-14 years), median Glasgow coma score (GCS) of 9 (3-15), and a mean pediatric trauma score of 8.3 ± 2.4. Seventy-nine (60.3%) patients were intubated; these patients received 139 (65.9%) of the 211 total fentanyl doses. No adverse effects from fentanyl were noted in flight record narratives. The median interval between fentanyl administration and postfentanyl vital sign assessment was 9.5 minutes (1-35 minutes). Median postfentanyl changes in SBP and HR were -4.7 and -2.9%, respectively. No patient became hypotensive after fentanyl administration. In nonintubated patients, mean postfentanyl SAT (99.2 ± 1.3%) was not significantly different (P = 0.70) from prefentanyl SAT (99.1 ± 1.3%), and no patient was noted to have clinically significant SAT decrement after fentanyl. Conclusion: Retrospective review of more than five years of prehospital fentanyl administration revealed no untoward events. Although prospective definitive demonstration of fentanyl's field use is pending, it is reasonable to continue discretionary fentanyl administration to injured pediatric children in pain.

Prehospital fentanyl analgesia in airtransported pediatric trauma patients

To review the 5.5-year safety record of a protocol guiding fentanyl administration to pediatric trauma patients undergoing aeromedical transport. Retrospective review of an urban aeromedical program's trauma scene responses from October 1991 to March 1997 identified the study population as all pediatric patients (age <15 years) receiving fentanyl for analgesia during air transport. Patients receiving fentanyl concurrently with other agents, eg, paralytics, were not studied. The air transport team consisted of a flight nurse and flight paramedic who provided protocol-driven patient care with off-line medical control. Study patients' flight records were reviewed to determine vital signs (systolic blood pressure [SBP], heart rate [HR], and oxygen saturation [SAT]) before and after fentanyl administration. Postfentanyl vital signs were reviewed for evidence of hemodynamic or ventilatory compromise. Pre- and postfentanyl vital signs were compared with the paired t test (P < 0.05). Flight records were also analyzed for narrative information, eg, naloxone administration and assisted ventilation, indicative of fentanyl side effects. Fentanyl (0.33-5.0 microg/kg) was administered 211 times to 131 patients who had a median age of 6.2 years (0.1-14 years), median Glasgow coma score (GCS) of 9 (3-15), and a mean pediatric trauma score of 8.3+/-2.4. Seventy-nine (60.3%) patients were intubated; these patients received 139 (65.9 %) of the 211 total fentanyl doses. No adverse effects from fentanyl were noted in flight record narratives. The median interval between fentanyl administration and postfentanyl vital sign assessment was 9.5 minutes (1-35 minutes). Median postfentanyl changes in SBP and HR were -4.7 and -2.9%, respectively. No patient became hypotensive after fentanyl administration. In nonintubated patients, mean postfentanyl SAT (99.2+/-1.3%) was not significantly different (P = 0.70) from prefentanyl SAT (99.1+/-1.3%), and no patient was noted to have clinically significant SAT decrement after fentanyl. Retrospective review of more than five years of prehospital fentanyl administration revealed no untoward events. Although prospective definitive demonstration of fentanyl's field use is pending, it is reasonable to continue discretionary fentanyl administration to injured pediatric children in pain.

Out-of-hospital use of neuromuscular-blocking agents in the united states

Objective. A national survey was mailed to state EMS directors to assess the current status of use of neuromuscular-blocking agents (NMBAs) by EMS systems across the United States. Methods. Initial and second mailings were completed in early 1996 and 1997, respectively. Results. Replies were received from all 50 (100%) states following the second mailing. Twenty-nine (58%) states use NMBAs. Eleven (22%) of the 29 use paralytic drugs only in aeromedical programs. Of the 18 states that use NMBAs in ground-based EMS systems, 11 (22%) use paramedic ambulance staffing exclusively. Registered nurses (RNs) or RN-paramedic teams comprised the majority of the remaining states' staffing configurations. The first reported date of implementation of use of NMBAs was 1985, and there has been a steady trend of additional states launching paralytic drug use over the last 12 years. Conclusion. This trend suggests that use of paralytic drugs by paramedics is becoming standard of care in many out-of-hospital systems.

Prehospital and emergency department analgesia for air-transported patients with fractures

Objective. To evaluate prehospital and receiving emergency department (ED) analgesia administration in air-transported patients with isolated fractures. Methods. The study was a retrospective descriptive analysis of flight and hospital records. Study patients were consecutive adults (not pharmacologically paralyzed) with fractures undergoing scene or interfacility helicopter transport during 1994–1996. The study aeromedical program uses two helicopters staffed by a nurse/paramedic flight crew providing protocol-guided care. The receiving ED was in an urban academic Level I trauma center (annual census 65,000). Primary data collected were timing and amount of prehospital and ED analgesia. Analysis was mainly descriptive, with chi-square and nonparametric methods used to compare patients who did and did not receive intratransport fentanyl. Results. 130 patients with isolated fractures underwent air transport during the study period 1994–1996. Of these, 98 (75.4%) received intratransport fentanyl; 20 of 98 (20.4%) received no analgesia in the receiving ED. Patients who did receive repeat analgesia in the receiving ED (n = 78, 79.6% of those receiving prehospital fentanyl) had a median interval of 42.5 minutes (interquartile range 25–100) between ED arrival and analgesia administration; only 62.8% of these patients received their ED analgesia within 60 minutes of arrival. Conclusions. Some patients receiving intratransport fentanyl received no ED analgesia, and those who did receive ED analgesia often had administration delays surpassing the clinical half-life of intratransport-administered fentanyl. Further study should investigate whether setting-specific analgesia practice differences reflect true differences in analgesia needs, overmedication by prehospital providers, or undermedication by ED staff.

Hospital and flight program reimbursement for patients transferred by helicopter

To determine the reimbursement status of a helicopter aeromedical program and its sponsoring hospital, the financial records of all patients transported by a university hospital-based helicopter aeromedical service during a one-year period of time were examined. The flight program was able to collect only 43% of patient charges, recouping only 24% of its operating costs. The hospital collected 57% of its total charges to patients transported by the helicopter aeromedical program. Reimbursers paying on a per-diem basis comprised 36% of the payors and had collection rates of 50% and 10% for the hospital and flight program, respectively. Cost-based insurers constituted 20% of the payors, provided 44% of program revenue, and had collection rates of 92% for the hospital and the flight program. If cost-based payors had reimbursed on rates similar to the per-diem payors, the hospital would have recovered only 49% of its charges and the flight program, would have recovered only 26% of its charges, recouping only 15% of its operating costs. In conclusion, reimbursement for helicopter aeromedical services and for the care provided in aeromedically transferred patients is poor. Sponsoring institutions are consequently subjected to significant financial stress that possibly challenges the fiscal viability of some programs.

Aeromedical evacuation of rural victims of nontraumatic cardiac arrest

To determine if the deployment of a helicopter-borne nurse/paramedic team contributed to survival of victims of nontraumatic cardiac arrest in a rural setting. Retrospective chart review. A university hospital-based helicopter aeromedical program serving a primarily rural region with a volunteer basic life support/advanced life support ground emergency medical services system. Victims of nontraumatic cardiac arrest, older than 15 years, in cardiac arrest at the time of request for air evacuation. Eighty-four patients were identified who met the study inclusion criteria between January 1, 1986, and December 31, 1989. Basic life support care was always available before aeromedical crew arrival; advanced life support care was available in 58% of cases before helicopter arrival. Resuscitative efforts were terminated in the field in 55 cases; of 29 patients transported to the emergency department, only ten (12%) survived to hospital admission. Only one patient (1%) survived to hospital discharge; this patient was resuscitated by ground advanced life support providers before helicopter arrival. Despite providing improved availability of advanced life support care in some cases, deployment of aeromedical teams had a negligible effect on patient survival from nontraumatic cardiac arrest in a rural setting.

Multicriteria analysis of aeromedical fleet expansion

We present an Expected Multiattribute Utility analysis of an aeromedical program's decision to add helicopters to its existing fleet. We approach the problem as one of helping the program's executive director to synthesize the relative value of the alternatives along technical dimensions so that he can present the alternatives to a decision making board that will weigh the technical merits against nontechnical dimensions, such as public perception, in deciding whether to expand the fleet. We develop criteria and simulation models to predict the joint probability distributions over these criteria for the different alternatives and use a combination of strength of preference and lottery-based questions in carefully planned utility assessments. To acknowledge difficulties in utility assessments, we perform a comprehensive sensitivity analysis of the utility information and note that our “best guess” results are fairly insensitive to the modeled variations. We propose the use of a “ratio of utility differences” to give a feel for the relative difference in the technical value between a given alternative and the status quo alternative, where the scale is the difference in value between another pair of alternatives easily perceived by the decision makers. This easy-to-use ratio implies that, although adding a helicopter to the program's fleet is optimal according to the technical dimensions, the additional “technical value” is small enough that the important nontechnical considerations could be expected to dominate the ultimate decision.

Poster 10 Evaluation of the effectiveness of an outreach aeromedical safety program

Poster 10 Evaluation of the effectiveness of an outreach aeromedical safety program

Tues 0830 Benefits of an out-reach aeromedical safety program

Tues 0830 Benefits of an out-reach aeromedical safety program

Assuring value from independent safety audits

Independent safety audits can be valuable management tools for an aeromedical program. Not only can they evaluate the program's present posture, but, if used properly, they can provide significant help in planning for a program's successful future. The phases of pre-safety audit planning safety audit accomplishment, and safety audit follow-up should be structured and well-thought out. Keep in mind that safety should be a non-negotiable element of an aeromedical program. Your operation can be as safe as management wishes it to be, but management must be willing to make the necessary personnel and financial investments. To that end I have a favorite truism which I first heard spoken by Robert Carney of Reed, Stenhouse Ltd. "If you think safety is expensive, wait until you have an accident!"

The evolution of air transport systems: A pictorial review

The air transport of patients began over seventy years ago in primitive biplanes. The ability to fly over the obstacles of the battlefield created enthusiasm in both the military and the medical communities. With the advent of vertical flight, the need for conventional runways was obviated allowing for casualties to be transported directly from the site of injury. After their introduction as air ambulances in 1945, helicopters soon supplanted ground ambulances with their speed and versatility. By the mid-1960s, civiliain casualties were being transported by helicopter as regional trauma care developed in the United States. Today aeromedical programs continue to expand rapidly, even as closer scrutiny of their efficacy, cost, and safety are explored. A pictorial review highlighting the evolution of air transport systems is presented.

False reports have aeromedical programs baffled

False reports have aeromedical programs baffled

A-4 Use of intraosseous infusions by aeromedical programs

A-4 Use of intraosseous infusions by aeromedical programs

C-10 The effect of two nearby fatal aeromedical helicopter crashes on the mission requests of a hospital-based aeromedical program

C-10 The effect of two nearby fatal aeromedical helicopter crashes on the mission requests of a hospital-based aeromedical program