Air Medical Evacuation Research Articles

In-Flight Auscultation During Medical Air Evacuation: Comparison Between Traditional and Amplified Stethoscopes

ObjectivesThe aim of this study was to evaluate the capacity of a traditional stethoscope versus an electronically amplified one (expected to reduce background and ambient noise) to assess heart and respiratory sounds during medical transport. Materials and MethodsIt was a prospective, double-blinded, randomized performed study. One traditional stethoscope (Littmann Cardiology III; 3M, St Paul, MN) and 1 electronically amplified stethoscope (Littmann 3200, 3M) were used for our tests. Heart and lung auscultation during real medical evacuations aboard a medically configured Falcon 50 aircrafts were studied. The quality of auscultation was ranged using a numeric rating scale from 0 to 10 (0 corresponding to “I hear nothing” and 10 to “I hear perfectly”). Data collected were compared using a t-test for paired values. ResultsA total of 40 comparative evaluations were performed. For cardiac auscultation, the value of the rating scale was 4.53 ± 1.91 and 7.18 ± 1.88 for the traditional and amplified stethoscope, respectively (paired t-test: P < .0001). For respiratory sounds, quality of auscultation was estimated at 3.1 ± 1.95 for a traditional stethoscope and 5.10 ± 2.13 for the amplified one (paired t-test: P < .0001). ConclusionsThis study showed that practitioners would be better helped in hearing cardiac and respiratory sounds with an electronically amplified stethoscope than with a traditional one during air medical transport in a medically configured Falcon 50 aircraft.

Medical evacuations from oil rigs off the Gulf Coast of the United States from 2008 to 2012: reasons and cost implications.

To identify reasons for air medical evacuations from oil rigs/platforms. Retrospective review of data of medical calls from 102 rigs/platforms in the US Gulf Coast from 2008 through 2012 with specific analysis of medevacs. On average, 1609 total calls per year relating to illness or injury on the 102 oil rigs/platforms with 4% to 7% requiring medical air evacuation. On average, 77% of medevacs were for nonoccupational medical injury or illness. Illness, not occupational injuries, is identified as the major reason for medical evacuations from oil rigs. Heart disease is the leading cause of chronic health conditions resulting in a medevac.

Managing Acute Coronary Syndrome During Medical Air Evacuation from a Remote Location At Sea

Managing Acute Coronary Syndrome During Medical Air Evacuation from a Remote Location At Sea

Temporary and definitive external fixation of war injuries: use of a French dedicated fixator

External fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years. The tactics of Percy Fx (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad. Overall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad. Temporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.

Managing Acute Coronary Syndrome During Medical Air Evacuation from a Remote Location at Sea

Coronary emergencies at sea requiring air evacuation are not uncommon. On board a Nimitz-class aircraft carrier while in a remote location, an active duty sailor suffered a myocardial infarction. A medical evacuation by helicopter was necessary. Transfer proved difficult due to the ship's location, poor flying conditions, and the patient's deteriorating condition. This case stresses the importance of expeditious diagnosis, treatment, and air transfer to shore-based facilities capable of providing definitive coronary care. A 33-yr-old man recently started on trazodone due to depression complained of chest pain. The patient was hemodynamically unstable and electrocardiogram showed ST segment elevation and Q waves in the anterior, inferior, and lateral leads. He was air-lifted to the nearest accepting facility with cardiac catheterization capabilities, which was over 300 miles away. Poor weather conditions hindered the pilot's ability to fly the original course. The patient remained critical and medication choices were limited. Even with all of these obstacles, everyone involved performed his or her duties admirably. The patient's condition improved by the time the helicopter landed. He was then rushed by ambulance to the hospital's coronary care unit, where he was successfully treated. This case highlights the need to keep a high index of suspicion when patients complain of chest pain, regardless of age. It is of the utmost importance that individuals capable of thinking and acting quickly are assigned to medical evacuation teams, and that they continue to train regularly, as coronary events at sea are not uncommon.

Thromboprophylaxis and VTE Rates in Soldiers Wounded in Operation Enduring Freedom and Operation Iraqi Freedom

US soldiers suffer catastrophic injuries during combat. We sought to define risk factors and rates for VTE in this population. We gathered data each hospital day on all patients injured in Afghanistan or Iraq who were admitted to the Walter Reed Army Medical Center (WRAMC). We analyzed prophylaxis rates and efficacy and identified risk factors for VTE. We recorded data on 506 combat casualties directly admitted to WRAMC after medical air evacuation. The average injury severity score for the group was 18.4 ± 11.7, and the most common reason for air evacuation was injury by improvised explosive device (65%). As part of the initial resuscitation, patients received 4.7 ± 9.0 and 4.00 ± 7.8 units of packed RBCs and fresh frozen plasma, respectively, and 42 patients received factor VIIa. Forty-six patients (9.1%) were given a diagnosis of VTE prior to discharge, 18 (3.6%) during air evacuation, and 28 (5.5%) during the hospital stay. In Cox regression analysis, administration of 1 unit of packed RBCs was associated with a hazard ratio (HR) of 1.04 (95% CI, 1.02-1.07; P = .002), and enoxaparin, 30 mg bid, administered subcutaneously for the majority of hospital days was associated with a HR of 0.31 (95% CI, 0.11-0.86; P = .02) for VTE during the hospitalization. Patients who suffer traumatic injuries in combat overseas are at high risk for VTE duringevacuation and recovery. Those with large resuscitations are at particularly high risk, and low-molecular-weight heparin is associated with a decrease in VTE.

Prehospital Use of Tranexamic Acid for Hemorrhagic Shock in Primary and Secondary Air Medical Evacuation

IntroductionMajor hemorrhage remains a leading cause of death in both military and civilian trauma. We report the use of tranexamic acid (TXA) as part of a trauma exanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian primary and secondary air medical evacuation (AME) helicopter EMS program. MethodsTXA was introduced into our CCP flight paramedic program in June 2011. Indications for use include age > 16 years, major trauma (defined a priori based on mechanism of injury or findings on primary survey), and heart rate (HR) > 110 beats per minute (bpm) or systolic blood pressure (SBP) < 90 mmHg. Our protocol, which includes 24-hour online medical oversight, emphasizes rapid initiation of transport, permissive hypotension in select patients, early use of blood products (secondary AME only), and infusion of TXA while en route to a major trauma center. ResultsOver a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111 bpm [95% CI 90.71–131.90], SBP of 91 mmHg [95% CI 64.48–118.60], and Glascow Coma Score of 7 [95% CI 4.65–9.96]. For primary AME, average response time was 33 minutes [95% CI 19.03–47.72], scene time 22 minutes [95% CI 20.23–24.27], and time to TXA administration 32 minutes [95% CI 25.76–38.99] from first patient contact. There were no reported complications with the administration of TXA in any patient. ConclusionWe report the successful integration of TXA into a primary and secondary AME program in the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed to assess the effect of such a protocol in this patient population.

Stratification of Patients in Long-Distance, International, Fixed-Wing Aircraft

IntroductionA growing number of individuals with significant medical histories travel for business and holidays. Precise anticipation and stratification of transport-relevant illness severity in the planning stage of an air medical evacuation is crucial for mission success and patient safety. MethodsWe developed a staging system (ie, Stratification of Air Medical Transport by Expression of Symptoms in Patients [STEP]) and applied it to 356 patients transported by a fixed wing aircraft between January 2010 and June 2011. Patients were stratified before transport, and the transport team performed independent staging of each patient during the actual transport. Data on transport modes, transport time, age, sex, diagnosis, the need for mechanical ventilation, and transport-related complications were collected. Data were analyzed for significant differences in STEP categories between operations staging and staging by the flight crew and for the correlation between operations STEP staging and actual transport acuity. ResultsComplete datasets were available in 353 of 356 patients. Differences between staging by operations and flight crew were documented in 31 cases (P = .809); in 18 of them, the flight crew considered the patient to be more severely affected than previously estimated. Decisions for specific transport mode and configuration were found to be adequate in all but 3 cases (99.15%). ConclusionSTEP is a useful tool to assess patient's illness/injury severity in the planning stage of a long distance, international, air ambulance transport and assists in choosing the appropriate mode and configuration of transport.

Distal Fibula Fracture Diagnosed With Ultrasound Imaging

The patient was a 31-year-old man serving in a military special forces unit at a remote location. He presented to a physical therapist with a chief complaint of worsening right lateral ankle pain that limited his ability to bear weight. Because the patient met the Ottawa ankle rules and there was concern for a fracture, radiographs were indicated. However, the nearest facility with radiographic capabilities was only available through air medical evacuation. Therefore, the physical therapist assessed the patient's ankle with an onsite portable ultrasound imaging unit, which demonstrated cortical irregularity along the distal fibula.

Emergent Interfacility Evacuation of Critical Care Patients in Combat

AbstractDuring the Second Iraq War (Operation Iraqi Freedom), high-intensity, low-utilization medical and surgical services, such as neurosurgical care, were consolidated into a centralized location within the combat zone. This arrangement necessitated intra-theater air medical evacuation of critically ill or injured patients from outlying combat support hospitals (CSH) to another combat zone facility having the needed services. A case series is presented of intratheater transfer of neurosurgical patients in Iraq during 2005-06. Ninety-eight patients are included in the series, with typical transfer distances of 40 miles (approximately 20–25 minutes of flight time). All patients were transported with a CSH nurse in addition to the standard Army EMT-B flight medic. Seventy-six percent of cases were battle injury, 17% were non-battle injuries, and the balance were classified as non-injury mechanisms. Seventy-six percent of cases were head injuries, with the balance involving burns, stroke, and other injuries. At 30 days, 12% of the patients had died, and 9% remained hospitalized in a critical care setting. None of the patients died during evacuation. Intratheater and interfacility transfer of critical care patients in the combat theater often involves severely head-injured and other neurosurgical cases. Current Army staffing for helicopter transport in these case requires a nurse or other advanced personnel to supplement the standard EMT-B flight medic.

Collective Air Medical Evacuation: The French Tool

The cornerstone of the current concept of military medical operations is the function, fit, and form of the provision of en route care. The life-saving capability of far-forward surgery creates the need for a new and unique ability: to move stabilized, but not necessarily stable, patients. The current system of en route care serves as a primary and indispensable portion of the continuum of critical care. 1 Venticinque SG Grathwohl KW Critical care in austere environment: providing exceptional care in unusual places. Crit Care Med. 2008; 36: S284-S292 Crossref PubMed Google Scholar , 2 Beninati W Meyer MT Carter TE The critical care air transport program. Crit Care Med. 2008; 36: S370-S376 Crossref PubMed Google Scholar , 3 Carlton PK Jenkins DH The mobile patient. Crit Care Med. 2008; 36: S255-S257 Crossref PubMed Google Scholar Without the capability of moving patients, the ability to do far forward surgery would be meaningless. 4 Holcomb JB Stansbury LG Champion HR et al. Understanding combat casualty care statistics. J Trauma. 2006; 60: 397-401 Crossref PubMed Scopus (243) Google Scholar , 5 Johannigman JA Maintaining the continuum of en route care. Crit Care Med. 2008; 36: S377-S382 Crossref PubMed Google Scholar

Air Medical Evacuations from a Developing World Conflict Zone

Somalia has been without effective government for close to two decades, with more than 1 million people internally displaced. The political unrest persists, with United Nations-backed African Union peacekeeping forces supporting the Transitional National government of Sharif Ahmed, struggling to maintain control of central Mogadishu from Islamist extremist groups, such as the reportedly Al-Qaeda-backed Al-Shabab. The African Union force of 5,000 troops is predominantly of Ugandan and Burundian origin, making up the African Mission in Somalia (AMISOM) effort. However, its mandate is limited to operations only in Mogadishu, and it is unauthorized to actively pursue insurgents. As with other ongoing high-profile conflicts, African Union troops face an enemy that blends into the civilian populace, fighting with a lethal mixture of improvised explosive devices and suicide bombers.

Auscultation in Flight: Comparison of Conventional and Electronic Stethoscopes

Objectives The ability to auscultate during air medical transport is compromised by high ambient-noise levels. The aim of this study was to assess the capabilities of a traditional and an electronic stethoscope (which is expected to amplify sounds and reduce ambient noise) to assess heart and breath sounds during medical transport in a Boeing C135. Methods We tested one model of a traditional stethoscope (3MTM Littmann Cardiology IIITM) and one model of an electronic stethoscope (3MTM Littmann Stethoscope Model 3000). We studied heart and lung auscultation during real medical evacuations aboard a medically configured C135. For each device, the quality of auscultation was described using a visual rating scale (ranging from 0 to 100 mm, 0 corresponding to “I hear nothing,” 100 to “I hear perfectly”). Comparisons were accomplished using a t-test for paired values. Results A total of 36 comparative evaluations were performed. For cardiac auscultation, the value of the visual rating scale was 53 ± 24 and 85 ± 11 mm, respectively, for the traditional and electronic stethoscope (paired t-test: P = .0024). For lung sounds, quality of auscultation was estimated at 27 ± 17 mm for traditional stethoscope and 68 ± 13 for electronic stethoscope (paired t-test: P = .0003). The electronic stethoscope was considered to be better than the standard model for hearing heart and lung sounds. Conclusion Flight practitioners involved in air medical evacuation in the C135 aircraft are better able to practice auscultation with this electronic stethoscope than with a traditional one.

Evaluation of a Specific Score for Air Medical Evacuation Triage

Age, local resources, and locations have been identified as independent factors indicating the need for immediate air medical evacuation. This preliminary case-control study aimed to evaluate the relevance of a score from 0 to 6 based on these criteria and to identify thresholds. The 3-step scale we obtained may help in prioritizing repatriation requests.

Main Importance of Training in Air-Medical Evacuation

Main Importance of Training in Air-Medical Evacuation

Sports Injuries In The U.s. Air Force, Marines, And Navy During Deployments For Operation Iraqi Freedom (march 2003 - May 2008)

Sports were a significant cause of non-combat injuries (NCI) for the U.S. military services, representing the 3rd leading cause of injury hospitalizations (13%) in 2006. Among Army soldiers deployed for Operation Iraqi Freedom (OIF) from 2001 to 2008, sports were the leading cause of NCIs (21%; rate: 2.3/10,000 person-years) that required medical air evacuation (AE) from OIF. The impact of sports as a cause of NCI among deployed service members (SM) from the Air Force (USAF), Marines (USM), and Navy (USN) is unknown. PURPOSE: To determine the incidence of sports-related injuries that required air evacuation of SMs in the USAF, USM, and USN while deployed for OIF and describe the distribution of sports injuries by sport, injury type, and anatomical location. METHODS: SMs (USAF, USM, and USN) medically air evacuated from OIF for an NCI were identified from AE records for the period March 2003 to May 2008. In addition to demographic and administrative details, AE records included medical information such as patient history and diagnosis. Records were reviewed for injury cases to identify the injury cause, diagnosis, and location. For each service, descriptive statistics were used to describe the distribution of sports injuries by sport, injury type, and location. RESULTS: Of 7,838 SMs (non-Army) air evacuated from OIF (USAF: n=1,608; USM: n=4,949; USN: n=1,281), 2,478 had an NCI (USAF: n=536; USM: 1,465; USN: n=477). Overall (23%), and for each service, sports were the leading cause of NCIs (USAF: 31%; USM: 21%; USN: 22%). Leading injury sport activities were basketball (25%), wrestling/martial arts (18%), football (15%), and weight lifting (14%), but rank order and proportions differed by service. Leading injury types were fracture (36%), sprain/strain/rupture (24%), and dislocation (16%). Leading injury sites were ankle/foot (22%), knee (20%), wrist/hand (14%), and shoulder (10%). CONCLUSION: Sports were the leading cause of NCIs medically air evacuated from OIF (March 2003 - December 2008) for the USAF (31%), USM (21%), and USN (22%). Only the USAF had a significantly higher proportion of sports injuries compared to the previously reported sports injury proportion among deployed U.S. Army soldiers (21%).

Airmedical Evacuation during a Mass-Casualty Incident in a Remote Location

Airmedical Evacuation during a Mass-Casualty Incident in a Remote Location

Large-Scale Airmedical Transport from a Peripheral Hospital to Level-1 Trauma Centers after Remote Mass-Casualty Incidents in Israel

Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs. The available data on airmedical transport from remote MCIs are limited.The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs. The study was retrospective and reviewed descriptive records of airmedical transports. The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch.The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome. The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

Role of Air-Medical Evacuation in Mass-Casualty Incidents—A Train Collision Experience

On 21 June 2005, a passenger train collided with a truck near Revadim, Israel. The collision resulted in a multiple-scene mass-casualty incident in an area characterized by difficult access and a relatively long distance from trauma centers. A major disaster response was initiated by civilian and military medical forces including the Israeli Air Force (IAF) Search and Rescue teams. The air-medical evacuation from the accident site to the trauma centers, the activities of the airborne medical teams, and the lessons learned from this event are described in this report. A retrospective analysis of data gathered from relevant elements that participated in management, treatment, and evacuation from the accident site was conducted. The accident resulted in 289 injured passengers and seven of the injured were killed. Six helicopters (performing nine sorties) participated. Helicopters evacuated trauma victims and aided in transporting air-medical teams to the site of the collision. Overall, 35 trauma victims (10 urgent) were evacuated by air to trauma centers. The length of time between the first helicopter landing and completion of the air evacuation was 83 minutes. The air-medical evacuation operation was controlled by the commander of the IAF Search and Rescue. Different crew compositions were set in real time. Air-medical evacuation during this unique event enabled prompt transportation of casualties from the scene to trauma centers and provided reasonable distribution of patients between various centers in the region. This operation highlighted the necessity for flexibility in medical decision-making and the need for nonconventional solutions regarding crew compositions during management of an airborne evacuation in similar settings. Air-medical evacuation should be considered as a part of responses to mass-casualty incidents, especially when the site is remote or characterized by accessibility difficulties.

The Effect of a Hypobaric, Hypoxic Environment on Acute Skeletal Muscle Edema after Ischemia-Reperfusion Injury in Rats

Clinicians have postulated that decreased atmospheric pressure during air evacuation exacerbates muscle edema and necrosis in injured limbs. The present study investigated whether the mild hypobaric, hypoxic conditions of simulated flight during muscle reperfusion worsened muscle edema and muscle injury in an established animal model. Twenty male Sprague-Dawley rats underwent tourniquet-induced hind limb ischemia for 2h. After removal of the tourniquet, rats were divided into two groups (n=10/group), and exposed to either (1) hypobaric, hypoxic conditions (HB) of 522 mm Hg (simulating 10,000 feet, the upper limit of normal aircraft cabin pressure), or (2) normobaric, normoxic conditions (NB) of 760 mm Hg (sea level), for 6h. Muscle wet weight, muscle dry:wet weight ratios, viability, and routine histology were measured on the gastrocnemius and tibialis anterior muscles. Blood samples were analyzed for percentage hematocrit, leukocyte count, and coagulation status. Ischemia resulted in significant edema in both groups (P<0.05). Normobaric normoxia caused greater edema in the gastrocnemius compared with hypobaric hypoxia; the tibialis anterior was not significantly different between groups. The decrease in body weight for NB and HB was 3.4+/-1.4 and 10.7+/-1.2g, respectively (P<0.05). Hematocrit was 44.7+/-0.5 and 42.6+/-0.6 (P<0.05). The hypobaric, hypoxic conditions of simulated medical air evacuation were not associated with increased muscle edema following 2h of ischemic injury. This suggests that other factors, such as resuscitation, may be the cause of muscle edema in flight-evacuated patients.