Air Medical Transport Program Research Articles

Establishing, Measuring, and Achieving a Minimum Proficiency Standard with Point-of-Care Ultrasound Among Clinicians in an Air Medical Transport Program

Establishing, Measuring, and Achieving a Minimum Proficiency Standard with Point-of-Care Ultrasound Among Clinicians in an Air Medical Transport Program

How Crisis Creates Leaders and New Opportunities in Education

Article| April 2022 How Crisis Creates Leaders and New Opportunities in Education Amy Gallagher Amy Gallagher Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor April 2022, Vol. 86, 38. https://doi.org/10.1097/01.ASM.0000827008.38731.91 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Amy Gallagher; How Crisis Creates Leaders and New Opportunities in Education. ASA Monitor 2022; 86:38 doi: https://doi.org/10.1097/01.ASM.0000827008.38731.91 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: covid-19, disasters, leadership, pandemics Steven Bott, MD is well versed in crisis management. His roles include cardiac and trauma anesthesiologist at the University of Utah, and medical director, flight physician, and mechanical circulatory support transport program director with AirMed, the university's critical care air medical transport program that represents six helicopters, two airplanes, and 10 separate flight teams 24/7. He had also commanded a federal Disaster Medical Assistance Team (DMAT) for 10 years, an experience that proved critically important during the pandemic. “As the pandemic pushed people out of their comfort zones, strong leaders emerged in the process,” said Dr. Bott. DMATs, operated by the National Disaster Medical System (NDMS), are designed to provide high-quality rapid-response medical care when natural or man-made disasters overwhelm state, local, tribal, or territorial resources. After leading emergency response teams in the aftermath of hurricanes Katrina, Harvey, and others, Dr. Bott already knew how to work in a rapidly... You do not currently have access to this content.

Development, Implementation, and Assessment of a New Competency and Outcomes-Based Orientation in an Air Medical Transport Program

ObjectiveThe development and evaluation of new employees in air medical transport has historically lacked standardization and competency-based learning goals. Here we discuss the development, implementation, and assessment of a new competency-based education and evaluation method at Geisinger's Life Flight air medical transport service. MethodsUsing Bloom's taxonomy of learning, 14 competencies for flight employees were identified. An electronic database was created to track progress across competencies and serve as an information repository for the identification of goals and the development of individualized learning plans. Ten months after implementation of the new method, 11 preceptors and education team members were surveyed to understand their views on the new program. ResultsAt the time of survey administration, 20 orientees had completed orientation under the new education and evaluation program in an average of 6.45 weeks, with a range of 3 to 10 weeks. Of the 11 surveyed instructors, 81.1% definitely agree that the new method adequately assesses performance compared with 45.5% with the previous unstandardized method; 81.8% of the instructors rated the overall change as very helpful. ConclusionThe adoption of a competency-based learning model for air medical transport employee education and evaluation improves the assessment of performance and allows for the development of customized learning plans.

Storytelling as a Tool for Vicarious Learning among Air Medical Transport Crews

Learning vicariously from the experiences of others at work, such as those working on different teams or projects, has long been recognized as a driver of collective performance in organizations. Yet as work becomes more ambiguous and less observable in knowledge-intensive organizations, previously identified vicarious learning strategies, including direct observation and formal knowledge transfer, become less feasible. Drawing on ethnographic observations and interviews with flight nurse crews in an air medical transport program, I inductively build a model of how storytelling can serve as a valuable tool for vicarious learning. I explore a multistage process of triggering, telling, and transforming stories as a means by which flight nurses convert the raw experience of other crews’ patient transports into prospective knowledge and expanded repertoires of responses for potential future challenges. Further, I highlight how this storytelling process is situated within the transport program’s broader structures and practices, which serve to enable flight nurses’ storytelling and to scale the lessons of their stories throughout the entire program. I discuss the implications of these insights for the study of storytelling as a learning tool in organizations, as well as for revamping the field’s understanding of vicarious learning in knowledge-intensive work settings.

Taking the Blood Bank to the Field: The Design and Rationale of the Prehospital Air Medical Plasma (PAMPer) Trial

Hemorrhage and trauma induced coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. Interest in the use of prehospital plasma in hemorrhaging patients as a primary resuscitation agent has grown recently. Trauma center-based damage control resuscitation using early and aggressive plasma transfusion has consistently demonstrated improved outcomes in hemorrhaging patients. Additionally, plasma has been shown to have several favorable immunomodulatory effects. Preliminary evidence with prehospital plasma transfusion has demonstrated feasibility and improved short-term outcomes. Applying state-of-the-art resuscitation strategies to the civilian prehospital arena is compelling. We describe here the rationale, design, and challenges of the Prehospital Air Medical Plasma (PAMPer) trial. The primary objective is to determine the effect of prehospital plasma transfusion during air medical transport on 30-day mortality in patients at risk for traumatic hemorrhage. This study is a multicenter cluster randomized clinical trial. The trial will enroll trauma patients with profound hypotension (SBP ≤ 70 mmHg) or hypotension (SBP 71–90 mmHg) and tachycardia (HR ≥ 108 bpm) from six level I trauma center air medical transport programs. The trial will also explore the effects of prehospital plasma transfusion on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research with an investigational new drug approval from the U.S. Food and Drug Administration utilizing a multipronged community consultation process. It is one of three ongoing Department of Defense-funded trials aimed at expanding our understanding of the optimal therapeutic approaches to coagulopathy in the hemorrhaging trauma patient.

Design of the Study of Tranexamic Acid during Air Medical Prehospital Transport (STAAMP) Trial: Addressing the Knowledge Gaps

Hemorrhage and coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. The development of trauma-induced coagulopathy and hyperfibrinolysis is associated with poor outcomes. Interest in the use of tranexamic acid (TXA) in hemorrhaging patients as an antifibrinolytic agent has grown recently. Additionally, several reports describe immunomodulatory effects of TXA that may confer benefit independent of its antifibrinolytic actions. A large trial demonstrated a mortality benefit for early TXA administration in patients at risk for hemorrhage; however, questions remain about the applicability in developed trauma systems and the mechanism by which TXA reduces mortality. We describe here the rationale, design, and challenges of the Study of Tranexamic Acid during Air Medical Prehospital transport (STAAMP) trial. The primary objective is to determine the effect of prehospital TXA infusion during air medical transport on 30-day mortality in patients at risk of traumatic hemorrhage. This study is a multicenter, placebo-controlled, double-blind, randomized clinical trial. The trial will enroll trauma patients with hypotension and tachycardia from 4 level I trauma center air medical transport programs. It includes a 2-phase intervention, with a prehospital and in-hospital phase to investigate multiple dosing regimens. The trial will also explore the effects of TXA on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research and thus required an investigational new drug approval from the U.S. Food and Drug Administration as well as a community consultation process. It was designed to address several existing knowledge gaps and research priorities regarding TXA use in trauma.

Public Relations and Marketing of the Air Medical Program

In the ever competitive world of the air medical industry, an increasing emphasis is placed on outreach, public relations, and marketing of the air medical transport program's services. These efforts can, in a very literal sense, determine whether a flight program is successful, fails, or simply dwells in a perpetual state of mediocrity. The single greatest driving force determining failure or success is volume, and the pursuit of that transport volume is fraught with both intrinsic and extrinsic complexities.

Air Medical Transport Curriculum Provides Education for Medical Students

Introduction Increased regionalization of healthcare will most likely result in greater utilization of air medical transport (AMT). Education of providers regarding the utilization and capabilities of AMT will be important. This study was undertaken to determine whether our curriculum in AMT provided a useful and satisfying educational experience for medical students Methods The curriculum included three 6-hour fly-along sessions, 2 hours of lectures, 2 hours of case review, an 80-page syllabus listing articles and position papers, and a 3-page writing assignment. The study was a review of the participants' (1 st- and 2 nd-year medical students) test scores and postelective evaluation for 1 year. The setting was a two-helicopter AMT program based at an urban, university-affiliated level 1 trauma center. Twelve students (1/month) participated in the month-long elective. The students took a 20-item test before and after the elective and a 15-item postelective evaluation (5-point scale: very dissatisfied, dissatisfied, neutral, satisfied, very satisfied). A paired t-test was used to compare the mean pre-test and mean post-test scores. The evaluation data were analyzed descriptively. Results The mean number of correct responses on the post-test (M = 18.67, SD = 1.61) was significantly higher than the mean number of correct responses on the pretest (M = 13.83, SD = 2.17), P < .001. All students were either satisfied (56%) or very satisfied (44%) with the lectures and case review. Eleven (91%) were very satisfied with interaction with the crew, and nine (75%) were very satisfied overall (25% satisfied). Seven (58%) were very likely to use AMT in their career, two (16.7%) likely, two (16.7%) unsure, and one (8.3%) unlikely. Conclusions Our curriculum in AMT provided a useful and satisfying educational opportunity for medical students. Their knowledge of AMT increased, and all were satisfied or very satisfied with the didactics and the crew interaction. Most thought that they would use AMT in their career.

Air Medical Transport Personnel Experiences with and Opinions about Research

Introduction This study examined air medical transport (AMT) personnel's experiences with and opinions about prehospital and AMT research. Methods A Web-based questionnaire was sent to eight randomly selected AMT programs from each of six Association of Air Medical Services (AAMS) regions. Responders were defined by university association (UA) and AMT professional role. Results Forty-eight of 54 (89%) contacted programs and 536 of 1,282 (42%) individuals responded. Non-UA responders (74%) had significantly more work experience in emergency medical services (EMS) (13.5 ± 8.5 vs. 10.8 ± 8.3 years, P = .002) and AMT (8.3 ± 6.3 vs. 6.8 ± 5.7 years, P = .008), whereas UA responders (26%) had more research training (51% vs. 37%, P = .006), experience (79% vs. 59%, P < .001), and grants (7% vs. 2%, P = .006). By AMT role, administrators had the most work experience, and physicians had the most research experience. Research productivity of responders was low, with only 9% having presented and 10% having published research; and UA made no difference in productivity. A majority of responders advocated research: EMS (66%) and AMT (68%), program (53%). Willingness to participate in research was high for both EMS research (87%) and AMT research (92%). Conclusions Although AMT personnel were strong advocates of and willing to participate in research, few had research knowledge. For AMT personnel, disparity exists between advocating for and producing research.

Auscultation in flight: comparison of amplified and traditional stethoscopes

Many air medical transport programs use pulse oximeters, end-tidal carbon dioxide monitors and other devices as indirect measures of respiratory and cardiac status. Thus, these methods do not replace cardiac auscultation during flight, which may be needed to identify sudden critical change. And the ability to compare left-sided and right-sided breath sounds may be essential to confirm the appropriate placement of endotracheal tubes as well as to diagnose pneumothorax. The ability for auscultation 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 amplified stethoscope (which is expected to reduce background and ambient noise) to assess heart and breath sounds during medical transport in a FALCON 50 plane.

The King LT versus the Combitube: Flight Crew Performance and Preference

AbstrastIntroduction. Air medical personnel frequently face the challenge of the emergency airway. The Combitube is an airway device commonly used by emergency medical services (EMS) providers as either a primary or rescue airway. Objective. We sought to evaluate the performance and preference of air medical personnel using a newer laryngeal tube airway device, the King LT, versus the Combitube in a simulator model. Methods. Participants included flight physicians, nurses, and paramedics in our air medical transport program. Twenty-seven subjects participated. Participants received a 10-minute instructional program, and then had individual practice with each device. Participants were tested on the insertion of each device in a Laerdal SimMan. Rates of successful placement, time to successful placement, and practitioner preference were recorded. Perceived ease of insertion was measured on a five-point scale (1 = easy, 5 = difficult). Results. All 27 participants correctly placed each device. Mean time to placement was 24.4 seconds (standard deviation [SD] of 4.7 seconds) for the King LT and 37.9 seconds (SD of 5.9 seconds) for the Combitube. The difference in mean times was 13.5 seconds (p < 0.0001). For the participants' perceived ease of insertion, the mean score for the King LT was 1.3 and that for the Combitube was 2.5. Twenty-six of 27 participants preferred the King LT over the Combitube. Conclusions. The King LT was placed significantly faster than the Combitube and was also perceived as easier to place. Ninety-six percent of the participants preferred the King LT. Limitations include using a simulator model rather than a human model.

Cricothyrotomy in Air Medical Transport

Airway management is an essential skill for air medical transport (AMT) providers. The endpoint of airway maneuvers is a cricothyrotomy which may be live-saving if other measures fail. We reviewed cricothyrotomy cases in our AMT program to evaluate the success rate and the circumstances surrounding the procedure. This was a retrospective review of cases in which a cricothyrotomy was performed at the University of Utah AirMed flight program during the years of 1995 to 2004. Data included incidence, indications, complications, neurologic outcome, and success rates of the procedure. Of the 14,994 transports during the study period, 17 cricothyrotomies were performed. Airway obstruction by blood and/or vomit was the most frequent indication (47%) followed by airway edema/distorted anatomy (24%). The total number of cricothyrotomies decreased during the study period. Seven (41%) patients survived with a reasonable neurologic outcome. The remaining 10 patients died during initial treatment or subsequent hospitalization. Success rate of the procedure in our series was 100%. These results were compared with those of other cricothyrotomy studies. Cricothyrotomy has become less common as an emergency rescue technique. However, AMT personnel have a high success rate when performing the cricothyrotomy procedure. This rate is as high as or higher than other emergency personnel.

Effectiveness of a challenge-and-respond checklist in ensuring safety behavior compliance by medical team members at a rotor-wing Air Medical Program

Introduction Checklists are a frequently recommended strategy for minimizing human error in both the aviation and medical industries, yet checklist noncompliance is sometimes cited as a factor in untoward incidents. We evaluate the use of a challenge-and-respond checklist designed to ensure compliance with basic pre-departure safety preparations by medical personnel at a helicopter air medical program. Methods The studied helicopter air medical transport program uses an interactive, challenge-and-respond checklist prior to departure to verify completion of four operational safety items. This is a prospective, convenience sample evaluation of 33 observations in which a checklist violation was created artificially and detection of that violation by the transport team was measured by direct observation. Characteristics of the transport by time, site of origin, and patient acuity were also recorded. Undetected violations were corrected by the investigator prior to departure, ensuring operational safety. Results Seven of the violations (21.2%) were detected by the transport team during routine completion of the checklist. Team members with less than 3 years of experience in the program had a 10% detection rate (95% confidence interval [CI], 1.5-23.1), whereas those with greater than 3 years experience in the program had a 38.5% detection rate (95% CI, 12.0-65.0). In this sample, no other observed variable suggested an association with detection rates. Conclusion Routine completion of an interactive challenge-and-respond checklist by medical personnel had a low rate of detecting operational safety omissions in the studied helicopter critical care transport program. There was some difference in results by crew tenure.

Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts

Introduction Twenty-four hour availability creates physiological and psychological challenges for air medical teams. The 24-hour shift (24H) is a common staffing pattern in the air medical community. We report sleep dept and pre-duty activity patterns for 24H medical staff members at helicopter air medical transport programs. Methods An anonymous survey collecting self-reported sleep quantities for off-duty, immediate pre-duty, and on-duty periods, along with self-reported outside employment patterns, was distributed to medical team members at cluster sample of 10 rotor wing air medical programs selected by stratified random sample to ensure geographic and operational diversity. Both matched-sample comparisons of sleep quantities in different phases of the duty-cycle and independent-sample comparisons between staff with and without outside employment had 80% power to detect a difference in means of 60 minutes at a 0.05 two-sided significance level using the appropriate t-test. Descriptive statistics are also reported; means are reported with the standard deviation. Results A total of 138 surveys were returned (69.0%) and the 133 (66.5%) that were fully completed were utilized for analysis. 24H crewmembers average nearly the same amount of sleep in 24 hour periods on both duty and non-duty days (6.9 ± 1.3 v. 6.4 ± 1.8 hours, p = NS, range 3 - 10 for duty days and 4 - 10 for non-duty days). On duty, they average 1.1 ± 1.3 hours of sleep in the first half of their shifts (range 0 to 5) and 5.3 ± 1.4 hours in the overnight portion (range 2 - 9). The lowest amount of on-duty sleep reported in the past 30 days ranged from 0 to 6 hours, averaging 1.9 ± 1.7 hours. The minimum pre-duty sleep reported by 24H crewmembers prior to any shift in the past month averaged 4.6 ± 1.6 hours (range 0-8), with 3.8% having reported in the past month with no sleep before their 24-hour shift. Outside employment (OE) in addition to the flight position was common for 24H crewmembers (81.1% of respondents). Pre-duty sleep did not differ significantly between 24H crewmembers with and without OE, but 16.3% of surveyed 24H crewmembers with OE had reported for flight duty within eight hours of leaving OE within the past 30 days. Conclusion In the programs surveyed, 24H crewmembers completed an average duty cycle with little sleep debt and were unlikely to be sleepless prior to reporting for a shift. OE is common for 24H medical staff and some personnel report for flight duty within eight hours of leaving an OE position. As the industry considers the impact of fatigue on operational safety, shift length, on-duty rest, and outside employment will be important considerations.

Sidestream end-tidal carbon dioxide monitoring during helicopter transport

Introduction End-tidal carbon dioxide (EtCO 2) monitoring is standard of care for intubated patients. Sidestream technology also allows EtCO 2 monitoring in non-intubated patients. This is the first study to evaluate the feasibility of monitoring sidestream EtCO 2 on intubated and non-intubated patients during helicopter transport. Setting An air medical transport program serving two level 1 trauma centers. Methods In this prospective observational study, sidestream EtCO2 was monitored in 100 consecutive patients transported by helicopter. Flight nurses rated the difficulty posed by various factors of sidestream monitoring. An experienced flight nurse and a clinical engineer evaluated waveforms and EtCO 2 values. Results Only 1 of the 100 transported patients required a change from sidestream to mainstream EtCO 2 monitoring. Moisture was noted in the tubing of two patients, and one was changed to mainstream. Eleven patients had occluded nares but were not changed to mainstream monitoring. On a 5-point Likert scale, responses to statements regarding difficulty with length of tubing, patient tolerance, and interference with patient care produced mean scores of 0.5 (range, 0–3). Responses regarding difficulty securing the cannula yielded a mean score of 0.7 (range, 0–3). Of 1,685 (99%) recorded EtCO 2 values, 1,668 met pre-established criteria for “consistent.” Alveolar plateaus were identified in 81 of 94 (86%) patient waveforms by the flight nurse and 73 of 94 (78%) patient waveforms by the clinical engineer. Conclusion Sidestream EtCO 2 monitoring is feasible during air medical transport of both intubated and non-intubated patients. The mechanism was easy to use, and consistent numeric values and waveforms with alveolar plateaus were obtained in a large majority of readings.

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Airway and rapid sequence intubation quality assurance and improvement: Should airway management training be more intensive?

Introduction: Many organizations have guidelines or position papers for rapid sequence intubation (RSI) in the prehospital setting. Air medical transport programs routinely utilize RSI and assess their performance through quality assurance and improvement programs. We attempted to assess our airway management to determine the need to increase intensiveness of training and maintenance protocols.

Aborted air medical missions: A 4-year quality review of a Canadian province-wide air medical program

Introduction EHS LifeFlight, the air medical transport program for the province of Nova Scotia, is a rotor-wing program with fixed-wing backup. It flies more than 600 missions per year, but a varying, significant number of other requested missions are aborted. The purpose of this study was to examine the reasons for these cancellations and related pertinent descriptive data and evaluate the potential implications for patient care and quality service. Methods This study is a descriptive, retrospective review of all aborted missions between July 1, 1997, and June 30, 2001. Data source was the EHS LifeFlight computer patient care record database. Results A total of 2723 air medical requests were received during the study period. Of these, 1846 were completed flight missions (68%) and 876 were aborted missions (32%). Reasons for aborted missions included weather (30%), aircraft not required/not appropriate (27%), aborted by medical control physician (15%), aircraft out on another mission (11%), aircraft down for maintenance (9%), patient died before aircraft arrival (5%), no suitable landing zone (2%), and other (1%). Conclusions A significant percentage of requested missions are aborted in this program. Reasons vary, but 20% of missions canceled could have been performed with the availability of a second dedicated aircraft. Overall, weather is the number 1 reason for aborting a mission.

Wisconsin's flight for life 21 years later

How does an air medical transport program measure success? By the number of lives saved? An increase in transport requests and completed flights? Additional aircraft or an added ground ambulance service? Conversely, how do we measure failure or setbacks? By experiencing a flat or decreasing trend in transport numbers? By “downsizing” the number of aircraft or closing satellite operations?

Utility of difficult laryngoscopy screening methods for out-of-hospital intubation

Study objectives: Scoring systems for the assessment of difficult laryngoscopy, such as Mallampati score, measurement of oral opening, thyromental distance, and neck mobility, may have limited utility in the out-of-hospital setting where many patients undergoing intubation are not able to cooperate because of altered mental status or cervical spine immobilization. We determine the frequency of out-of-hospital intubations occurring in patients able to comply with common difficult laryngoscopy scoring systems. Methods: We conducted a retrospective review of a consecutive series of intubations at a university-based air medical transport program from January 1998 to September 2003. The records of all patients requiring oral intubation were reviewed. Exclusion criteria were age younger than 18 years and incomplete medical record data. Mallampati score and oral opening were judged to be unobtainable in patients who could not follow commands (Glasgow Coma Scale [GCS] motor score <6). Neck mobility and thyromental distance were deemed unobtainable in patients with cervical spine immobilization. Results: Four hundred twenty-three intubations were performed. Exclusion of 73 patients younger than 18 years and 19 patients with incomplete records yielded 331 intubations. Overall intubation success rate was 97%, and rapid sequence intubation was used in 77% of patients. Two hundred eighty (85%) patients had GCS motor score less than 6, and 235 (71%) patients were immobilized. Two hundred nine (63%) patients had GCS motor score less than 6 and were immobilized. Only 25 (8%) patients could follow commands and were not immobilized. Interrater reliability in recording of GCS scores and presence of spine immobilization was identical in 30 of 30 (100%) of randomly selected records. Conclusion: Only 8% of patients intubated in this out-of-hospital population could follow commands and were not immobilized, which severely limits the applicability of Mallampati scores, measurement of oral opening, thyromental distance, and neck mobility to predict difficult intubation in the out-of-hospital setting. Study limitations include retrospective data collection.