Air Medical Environment Research Articles

Inhaled Nitroglycerin for Pulmonary Edema in Air Medical Services: A Retrospective Pilot Study

ObjectiveThe use of traditional inhaled pulmonary vasodilators, such as nitric oxide, to treat symptomatic pulmonary edema is not practical in the air medical or prehospital environment because of difficulty with administration. A hospital-based critical care air medical transport service initiated a pilot study to investigate the use of inhaled nitroglycerin (iNTG) as an alternative pulmonary vasodilator. MethodsFor this pilot study, iNTG was administered using a jet nebulizer setup and concentrated nitroglycerin, both of which are widely available in acute care settings. In conjunction with medical oversight, transport personnel identified patients with respiratory distress secondary to pulmonary edema. Twenty-two months after initiating the protocol, a retrospective chart review was conducted. Data for patients receiving iNTG were retrospectively abstracted through a medical record search and manual chart review. ResultsTwelve patients received iNTG during the pilot study. Basic demographics, medical comorbidities, concurrent medications, laboratory values, and radiographic studies were collected for each patient. Basic statistics were performed to identify any potential trends. ConclusionThe administration of iNTG is feasible in an air medical transport setting and may provide a useful adjunct to treating patients with pulmonary edema and respiratory distress. Because iNTG delivery targets the pulmonary vasculature, this may be of particular benefit in patients with a poor hemodynamic profile. Larger randomized controlled or cohort studies are needed to specifically analyze and compare hemodynamics, diagnostics, and patient outcomes.

Prone Positioning of Ventilated Patients During Air Medical Evacuation: A Case Series

ObjectiveThe purpose of this study was to investigate patient safety implications of transporting prone-positioned mechanically ventilated patients in the air medical environment (AME). MethodsA retrospective health record review of patient encounters from 2019 to 2021 was conducted using British Columbia Emergency Health Services air medical electronic patient care reports. ResultsA total of 633 patients were identified as intubated, mechanically ventilated, and transported by British Columbia Emergency Health Services air medical teams. Ten patients were identified as having been transported in the prone position. Oxygen saturation, arterial blood oxygen levels, and carbon dioxide measurements from 8 cases indicated that patients remained stable or improved during transport. Cardiovascular episodes including hypotension and tachycardia were observed. In 2 patients, a mean 17.5% decline in oxygen saturation was identified. It could not be determined if this was a result of prone positioning during AME or due to a deteriorating physiological condition related to the patient's underlying disease. There were no identified tube dislodgments during AME transport. ConclusionAlthough proning did not compromise patient safety with respect to tube or line displacement in our study, we cannot draw definitive conclusions regarding the safety implications of proning on patient vital signs during transport.

Air Medical Ultrasound: Looking Back to See What We Have Learned for the Future

ObjectiveThis study attempts to replicate data from a similar study performed 5 years ago by comparing point-of-care (POCUS) extended focused abdominal sonography in trauma (eFAST) examinations performed by an air medical flight crew with those performed by a trauma team at a level 1 trauma center. MethodsThis prospective observational study evaluated 174 trauma patients over a 12-month period in southeastern Virginia and northeastern North Carolina. ResultsFor 101 trauma patients who had a POCUS evaluation completed by the flight crews, a positive predictive value of 100% was obtained with a negative predictive value of 96.63% for pneumothorax, hemothorax, and free abdominal fluid. This showed no significant difference in that of the trauma team's POCUS studies or that of the data from the 2017 study. Early recognition of life-threatening injury continues to be a priority during the assessment of traumatically injured patients. In conjunction with a thorough history and physical examination, POCUS is a very effective method to identify these potentially devastating injuries, especially in the air medical community. When we compared this study's results with those of our study from 2017, the data were very similar, showing that flight crews can conduct POCUS examinations effectively in the austere prehospital environment. ConclusionBy replicating this study, we have shown the validity and continued quality, accuracy, and benefits of the POCUS eFAST examination of trauma patients in the air medical environment. The validity of our previous and now current research suggests that some current standard trauma protocol revisions are indicated (ie, the initiation of air medical trauma resuscitation with blood products, preferably whole blood, and the transport of critically injured patients with a positive POCUS examination for free abdominal fluid directly to the operating room should be closely evaluated).

Cardiac Arrest in Flight: A Retrospective Chart Review of 92 Patients Transported by a Critical Care Air Medical Service

ObjectiveThe purpose of this study was to describe the incidence, characteristics, and outcomes of cardiac arrest in the air medical environment so that we can begin to understand predictors of in-flight cardiac arrest and identify opportunities to improve care. MethodsThis retrospective observational study was undertaken at Airlift Northwest from 2013 to 2017. Descriptive statistics of adult patients with medical and traumatic etiologies of cardiac arrest were analyzed and compared. ResultsOf the 13,915 adult patients transported during the study period, fewer than 1% (N = 92) had a cardiac arrest during transport. Of those, 42% in the overall cohort had return of spontaneous circulation on arrival at the destination hospital. Medical etiologies of cardiac arrest were more common than traumatic (65% vs. 35%), more likely to have an initial shockable rhythm (30% vs. 3%, P = .004), and more frequently arrived at the receiving hospital with return of spontaneous circulation (57% vs. 31%, P = .03). Rearrest in transport occurred frequently (39%). Most patients were hypotensive before cardiac arrest, and peri-intubation cardiac arrest occurred in 12% of patients. ConclusionCardiac arrest during air medical transport is a rare event that requires a high level of critical care to treat refractory cardiac arrests, hemodynamic instability, and airway compromise.

Is E-Learning Education Effective in Increasing the Ability of Nonphysician Medical Flight Crewmembers to Accurately Interpret Point-of-Care Lung and Cardiac Ultrasound Examinations?

ObjectivePatients suffering from severe injury or illness can benefit from the care and transport of helicopter emergency medical services (HEMS). This may be due to the speed of transport, level of care, expertise of flight crews, and access to specialized equipment and tools. One such tool is point-of-care ultrasound (POCUS). POCUS-based lung and cardiac evaluations can positively influence the assessment and care provided to critically ill HEMS patients, but how these procedures can best be learned by nonphysician flight crewmembers has not been fully explored. MethodsIn this prospective, interventional study, 26 flight crewmembers were evaluated before and after a succinct, guided educational intervention focused on the use of free open-access medical education material intended to help them acquire the knowledge needed to accurately identify and interpret POCUS assessments. ResultsAfter completing the educational intervention, participants had a statistically significant improvement in their postintervention scores. ConclusionThis study supports the use of free open-access medical education material in improving the knowledge needed for nonphysician flight crewmembers to interpret basic lung and cardiac ultrasound images. Integrating this information into educational programs may contribute to increased comfort and proficiency and serve to accelerate the adoption of this tool in the air medical environment.

Emotional Turmoil and Time Constraints Decrease the Ability of Team Members to Communicate Effectively and Make Decisions

Emotional Turmoil and Time Constraints Decrease the Ability of Team Members to Communicate Effectively and Make Decisions

Education Needs of Australian Flight Nurses: A Qualitative Study

ObjectiveFlight nurses work in physically challenging environments, often alone, in the confines of moving aircraft at altitudes with limited resources. Although this challenging environment has been previously described, there are no Australian studies that outline flight nurses’ learning needs and the education activities they find useful in learning about their role. MethodsThis was a qualitative exploratory study using one-on-one interviews with 8 currently practicing flight nurses from 1 air medical retrieval organization. Data were analyzed thematically. ResultsFour key themes emerged: flight nurses need to learn how to work autonomously in a resource-constrained air medical environment, flight nurses need to learn how to develop physical and mental resilience to work in the air medical environment, flight nurses need to learn nontechnical skills such as flexibility and adaptability, and flight nurses learn how to perform in their role through formal and informal learning strategies. ConclusionExisting clinical knowledge aids decision making as a sole practitioner in the resource-limited air medical environment. Previously unreported nontechnical skills of mental resilience, adaptability, and flexibility were highlighted. Flight nurses learn how to prepare for their role through simulation, case reviews, in situ observation through buddy flights, and a range of socially situated learning activities.

Ultrasound in the Air Medical Environment

Ultrasound in the Air Medical Environment

Addressing Current Issues with Standards

Medical transport is a very dynamic profession in this chaotic US health care environment where there are constant changes in technology and practice. Accreditation Standards are revised every 2 to 5 years depending on the changes and issues the board reviews during accreditation deliberations. Issues and concerns are brought to the Commission on Accreditation of Medical Transport Systems (CAMTS) by site surveyors, hospitals, operators, and emergency medical service constituents at large. There have been a number of blogs put out by CAMTS to provide insight into changes that will be included in the 11th Edition of Standards with board approval. The Aviation and Safety Advisory Committee also brings issues to the Board of Directors that they assess as potential risks or hazards in the air medical environment. The following represent some of the concerns that CAMTS will address in the 11th Edition Standards to be published in 2018. Eileen Frazer, RN, CMTE, is the CAMTS executive director. She can be reached at [email protected] and (864) 287-4177.

Safety and Efficacy of Thoracostomy in the Air Medical Environment

The use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraxes is potentially lethal and is often encountered in the prehospital environment. Air medical crew members have long performed thoracostomy but questions remain regarding safety, efficacy and survival. This study consists of a retrospective review of 250 patients undergoing prehospital thoracostomy performed by flight nurses and paramedics focusing on outcome, survival and complications.

The Reanimated Skill of Calculating Oxygen in the Air Medical Environment

The Reanimated Skill of Calculating Oxygen in the Air Medical Environment

Safety and Efficacy of Thoracostomy in the Air Medical Environment

ObjectiveThe use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraces are potentially lethal and are often encountered in the prehospital environment. MethodsThe authors reviewed the prehospital electronic medical records of patients who had undergone finger thoracostomy (FT) or tube thoracostomy (TT) while under the care of air medical crewmembers. Demographic data were obtained along with survival and complications. ResultsDuring the 90-month data period, 250 patients (18 years of age or older) underwent FT/TT, with a total of 421 procedures performed. The mean age of patients was 44.8 years, with 78.4% being male and 21.6% being female; 98.4% of patients had traumatic injuries. Cardiopulmonary resuscitation was required in 65.2% of patients undergoing FT/TT; 34.8% did not require cardiopulmonary resuscitation. Thirty percent of patients exhibited clinical improvement such as increasing systolic blood pressure, oxygen saturation, improved lung compliance, or a release of blood or air under tension. Patients who experienced complications such as tube dislodgement or empyema made up 3.4% of the cohort. ConclusionThe results of this study suggest that flight crews can use FT/TT in their practice on patients with actual or potential pneumothoraces with limited complications and generate clinical improvement in a subset of patients.

Noninvasive Mechanical Ventilation in Helicopter Emergency Medical Services Saves Time and Oxygen and Improves Patient and Mission Safety: A Pilot Study

Noninvasive mechanical ventilation (NIMV) is used increasingly in patients with severe respiratory distress and has clear benefits over standard medical therapy (SMT) in terms of patient safety. NIMV is particularly useful in cardiogenic acute pulmonary edema and in exacerbations of chronic obstructive pulmonary disease, both of which are frequent reasons for an emergency medical services dispatch. Early use of NIMV avoids complications in these patients in many cases. To date, the use of noninvasive positive-pressure ventilation in the air medical environment has been minimally researched. We evaluated NIMV versus SMT in the helicopter emergency medical services environment in patients with cardiogenic acute pulmonary edema and exacerbated chronic obstructive pulmonary disease. The parameters assessed were stabilization time, tolerance, safety, clinical response, and oxygen consumption. Bilevel noninvasive positive-pressure ventilation was the ventilatory mode used for all patients. The technique of NIMV in medical air transport is useful, easy to operate, and safe. It offers increased patient safety, reducing the need for invasive mechanical ventilation and its complications; better intervention times (35.8 minutes [NIMV] vs. 57.65 minutes [SMT], P < .05); improvement in aircraft operability; and a reduction in oxygen consumption (6.2 L/min vs. 9.8 L/min, P < .05), contributing to mission operability and safety.

Personal Survival Kits

The air medical environment presents a variety of potential hazards. One of these hazards, the possibility of an air medical crew being placed in a survival situation, is specifically mentioned in the Commission on Accreditation of Medical Transport Systems (CAMTS) accreditation standards.1 The incidence of this sort of occurrence is not known, and few reports exist of actual survival situations faced by air medical crews.

Airway Management in the Air Medical Setting

Background Airway management is a key component of air medical care for seriously ill and injured patients. This meta-analysis of the prehospital airway management literature explored the pooled air-medical placement success rates for oral endotracheal intubation (OETI), including rapid sequence intubation (RSI) and drug-facilitated intubation (DFI), nasotracheal intubation (NTI), blind insertion airway devices (BIAD), and surgical cricothyrotomy (SCRIC). Methods We performed a systematic literature search for all English language articles reporting success rates for airway procedures performed in the prehospital setting. After identifying articles specific to the air-medical environment, pooled estimates of success rates for each airway technique were calculated using a random effects meta-analysis model. Results Thirty-six unique studies, encompassing 4,574 procedures, reported airway management success rates in the air medical environment. The pooled estimates (95% CI) for intervention success across all clinicians and patients were: OETI (without RSI/DFI): 86.4% (81.2%–90.3%); DFI: 95.1% (84.1%–98.6%); RSI: 96.7% (94.8%–97.9%); NTI: 76.1% (71.9%–79.9%); BIAD: 94.0% (85.8%–97.6%); and SCRIC: 90.8% (80.6%–95.9%). Conclusion We provide pooled estimates for airway management procedural success rates in the air medical setting. These data can be used by program managers and medical directors in determining the most appropriate airway management procedures to incorporate into their services and for benchmarking in quality improvement activities.

Clinical Clearance of Spinal Immobilization in the Air Medical Environment: A Feasibility Study

Various decision algorithms have been developed for use in the prehospital setting to analyze those trauma patients who do not require spinal immobilization. The feasibility of applying these algorithms in the air medical transport environment has not been studied. All adult patients (>/=age 16) transported to three Level I trauma centers were eligible for the study. Medical crews completed a data collection sheet during transport which was later used to analyze whether the transported patient would be eligible for spinal clearance based on the absence of all of the following clinical findings: (1) abnormal level of consciousness; (2) evidence of intoxication; (3) distracting painful injury; (4) spinal tenderness or pain; or (5) abnormal neurologic examination. The outcomes were (1) the proportion of transported patients potentially eligible for spinal clearance and (2) the ability of the algorithm to predict spinal injury. Three hundred twenty-nine patients were enrolled in the study. Forty-nine (15%) had spinal injuries with 12 (24%) considered unstable. Only 40 patients met criteria for deferring spinal immobilization; 4 of these patients had spinal fractures. The algorithm had a sensitivity of 90% and a specificity of 16%. Clearance of spinal immobilization using prehospital clinical algorithms during air medical transport did not appear to be useful. These criteria were not found to be sensitive, specific, or predictive of spinal injury in this population of blunt trauma patients. Prehospital spinal immobilization clearance algorithms using existing criteria should not be adopted for patients transported by helicopter.

Fixed wing transport airway management utilizing a situational awareness paradigm

Airway management presents one of the most challenging and stress-provoking scenarios in the air medical environment. Imminent loss of the airway provokes anxiety in even the most seasoned medical professional. Mastery of both didactic information and requisite clinical skills is essential before the clinician encounters the difficult airway. The authors' paradigm of airway management incorporates situational awareness into difficult airway scenarios.1 The situational awareness paradigm focuses on a logical stepwise approach to addressing the difficult or deteriorating airway and emphasizes the clinician's physiologic response to the corresponding condition of situational awareness.

The potential of handheld trauma sonography in the air medical transport of the trauma victim

Air medical evacuation is an important means of reducing the time to definitive care for the acutely injured and has been credited with saving or extending the lives of many people. Out of necessity, medical care delivered during flight focuses on and is typically limited to correcting threats to physiologic stability. A review by Fisher documented the most common life-threatening conditions in a medical helicopter to be cardiac arrest (19%), airway obstruction (5%), cardiac tamponade (3%), and tension pneumothorax (2%). Trauma sonography has become an essential tool in trauma resuscitation. A body of controlled studies yields Level I recommendations for its use as the initial screening mode to rule out hemoperitoneum after blunt trauma. With technical developments and commercialization, portable handheld ultrasound is becoming increasingly available to clinicians and enhancing the way in which they examine patients. It is then intuitive that taking this extension of the physical examination outside of the hospital to the air medical environment has the potential to save lives. The Advanced Trauma Life Support course of the American College of Surgeons focuses on reducing preventable deaths in the early postinjury phase. Preventable deaths may be addressed by preventing airway obstruction, promptly treating hemo/pneumothoraces, and identifying and addressing intra-abdominal and intracerebral bleeding. These are also conditions that may manifest and be worsened in the transport environment and are more difficult to detect in flight than anywhere else. When faced with challenges, physicians historically have accepted new technology in a quest for better patient care. The first air medical mission was reportedly during the siege of Paris in 1870, when wounded soldiers were air-lifted out of the besieged city by balloon. Whether true or not, this spirit has transcended to the current day, where the trauma ultrasound has been used on the International Space Station in the absence of any other diagnostic imaging modes. The space station has no plan or capability for computed tomography, no x-ray, no magnetic resonance imaging. This limitation has necessitated looking outside the traditional ultrasound boxes to consider novel indications that might provide diagnostic information. Despite the catastrophic consequences a serious medical event in space would have for both the individual and the mission, there is only a relatively small number of potential victims. Many more lives are at stake considering air medical transport on earth, and we suggest that novel additions to the role of ultrasound might benefit the air medical transport environment, ultimately providing the greatest benefit to the most people.

Environmental cues used by advanced practice nurses in air medical services

Environmental cues used by advanced practice nurses in air medical services

The Role of the Flight Paramedic in Air Medical Safety and Crew Resource Management: Position statement of the National Flight Paramedics Association Approved by the NFPA Board of Directors on March 30, 2003

The National Flight Paramedics Association (NFPA) was formed as a nonprofit organization in 1986 and dedicated itself to promoting the global growth and development of the paramedic profession. During the time of NFPA's formation, the air medical community was plagued by an alarming accident rate that approached nearly 8 accidents per year. With attention drawn to the rising accident rate and public opinion turning, the air medical community began an internal process to attempt to minimize the danger. The NFPA and other air medical associations issued position papers defining the minimal protective equipment for those working in the rotor-wing air medical environment.