Flight Physicians Research Articles

Cervical Disc Displacement in Military Pilots.

Cervical disc displacement (CDD) may disqualify pilots from flying and have a profound impact on military unit capability. The objective of this retrospective database review is to characterize the incidence and demographic predictors of symptomatic cervical spine disc displacement in pilots of fixed- and rotary-wing aircraft and ground-based controls. The Defense Military Epidemiology Database was queried for first-occurrence ICD-9 code 722.0: CDD cases from 2007 to 2015. Injury count rates among aircraft groups and overall incidence per 1,000 person-years were calculated and standardized for age, gender, and military rank, and 95% confidence intervals (CIs) were compared to determine significance. There were 934 new cases of CDD among active duty U.S. Military pilots during the study period. The overall incidence of CDD in all pilots during this time frame was 2.715 per 1,000 person-years (95% CI, 2.603-2.830). Helicopter pilots had a significantly higher incidence compared to all other aircraft pilots and crew at 3.79 per 1,000 person-years (95% CI, 3.48-4.13). This finding remained statistically significant after standardizing for age, gender, and rank. Among all military officers, increasing age was a risk factor for CDD. The U.S. Military helicopter pilots have an increased risk compared to fixed-wing pilots and non-pilot controls. CDD remains a rare, though career-threatening, condition. Increased education and awareness training are warranted for both helicopter pilots and flight physicians to recognize signs and symptoms of cervical pathology. Continued investigations into preventive measures to minimize injury and time unfit for flight are warranted.

Gravitational Ischemia in the Brain: How Interfering with Its Release May Predispose to Either Alzheimer’s- or Parkinson’s-like Illness, Treatable with Hyperbaric Oxygen

The physiological mechanisms for releasing and resolving gravitational ischemia in the brain, and their susceptibility to malfunction, may play an important role in a variety of neurological illnesses. An astronaut on a space walk in a micro-gravity environment may be susceptible to neuro-ocular symptoms associated with unopposed gravity-resistance mechanisms for partially preventing gravitational ischemia in the brain, and for attenuating its impact—mechanisms which may be required for normal brain physiology on Earth. Astronauts on the International Space Station typically breathe a mixture of gasses similar in composition to what they breathed on Earth, following the 1967 death of three astronauts, including Ed White, by fire on the Apollo 1 spacecraft, which was carrying 100% oxygen. For the last decade, astronauts have been studied extensively by flight physicians regarding the commonly experienced symptoms of VIIP, or ‘visual impairment and intracranial pressure’ syndrome. In this paper, we compare VIIP syndrome to the neuro-ocular and Parkinson’s-like symptoms which occurred during and after the 1918–1919 influenza pandemic. The common denominator may be gravitational ischemia in the brain, and the mirror-imaging failed mechanisms for its release (in influenza) versus unopposed gravity-resistance mechanisms (in astronauts). Some research has suggested that astronauts may benefit from breathing oxygen concentrations somewhat higher than 20%, and under slightly elevated pressure. These may possibly prevent maladaptive mechanisms leading to Alzheimer’s- or Parkinson’s-like illness by compensating for impaired mechanisms for releasing and resolving gravitational ischemia in the brain.

Lateral Canthotomy Task Trainer in an Educational Small Group for Flight Providers

ObjectiveLateral canthotomy is a rare, emergent, vision-preserving procedure to treat orbital compartment syndrome. Using Ericsson's deliberate practice model, we aimed to develop a multimodal small group intervention including a modified low-fidelity task trainer to improve flight physician knowledge and technical competency for lateral canthotomy in the prehospital context. MethodsTwo cohorts of resident (postgraduate year 1) flight physicians received small group training during an all-day competency-based flight physician orientation. The first cohort completed self-report pre- and postintervention assessments. In the second cohort, examiners assessed pre- and postintervention performance. ResultsComparing pre- and postintervention responses (N = 27), the mean agreement with the knowledge of indications increased from 3.7 to 4.8. The mean agreement regarding confidence in skills increased from 2.2 to 4.2 (P < .001). The majority of participants (20/27) indicated the trainer “definitely helped,” whereas 7 of 27 residents indicated the trainer “somewhat helped” them to learn skills. Examiners assessed holistic learner performance (n = 13) as improved from a mean of 3.2 preintervention to 4.7 postintervention, with 11 of 13 learners demonstrating improvement (P < .005). ConclusionWe demonstrate the feasibility of a brief small group training combining multimodal didactics with a modified low-fidelity task trainer. Resident self-assessment and examiner assessment demonstrated improved procedural skill with lateral canthotomy.

Aviation Decompression Sickness in Aerospace and Hyperbaric Medicine

INTRODUCTION: The U.S. Navy experienced a series of physiological events in aircrew involving primarily the F/A-18 airframe related to rapid decompression of cabin pressures, of which aviation decompression sickness (DCS) was felt to contribute. The underlying pathophysiology of aviation DCS is the same as that of diving-related. However, based on the innate multifactorial circumstances surrounding hypobaric DCS, in clinical practice it continues to be unpredictable and less familiar as it falls at the intersect of aerospace and hyperbaric medicine. This retrospective study aimed to review the case series diagnosed as aviation DCS in a collaborative effort between aerospace specialists and hyperbaricists to increase appropriate identification and treatment of hypobaric DCS.METHODS: We identified 18 cases involving high-performance aircraft emergently treated as aviation DCS at a civilian hyperbaric chamber. Four reviewers with dual training in aviation and hyperbaric medicine retrospectively reviewed cases and categorized presentations as "DCS" or "Alternative Diagnosis".RESULTS: Reviewers identified over half of presenting cases could be attributed to an alternative diagnosis. In events that occurred at flight altitudes below 17,000 ft (5182 m) or with rapid decompression pressure changes under 0.3 atm, DCS was less likely to be the etiology of the presenting symptoms.CONCLUSIONS: Aviation physiological events continue to be difficult to diagnose. This study aimed to better understand this phenomenon and provide additional insight and key characteristics for both flight physicians and hyperbaric physicians. As human exploration continues to challenge the limits of sustainable physiology, the incidence of aerospace DCS may increase and underscores our need to recognize and appropriately treat it.Kutz CJ, Kirby IJ, Grover IR, Tanaka HL. Aviation decompression sickness in aerospace and hyperbaric medicine. Aerosp Med Hum Perform. 2023; 94(1):11-17.

In Memoriam: Hamit Ziya Gökalp, 1929 to 2022.

In Memoriam: Hamit Ziya Gökalp, 1929 to 2022.

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.

Ten minutes with Dr Gregory R Ciottone, MD, FACEP, FFSEM, President of the World Association for Disaster and Emergency Medicine

### Biography Dr Gregory R Ciottone is the President of the World Association for Disaster and Emergency Medicine. He is an Associate Professor at Harvard Medical School, and an Instructor...

Abstract 3: Comparison of Flight Physician operated Hyper-Angulated and Standard Geometry Video Laryngoscopy Tracheal Intubation on a Helicopter in a Manikin

Objective To investigate the efficacy of hyper-angulated video laryngoscopy (HAVL) versus standard-geometry video laryngoscopy (SGVL) during a simulated mid-flight helicopter intubation. Introduction Prehospital intubation is often complicated by poor conditions including bad lighting, poor patient positioning, excessive noise, and restricted cervical spine mobility – some of which are known predictors of a difficult airway. These factors are magnified in the setting of a mid-flight helicopter intubation. The specific aim of our investigation was to evaluate if use of a specific video laryngoscopy technique offers advantage in this situation. The SGVL technique requires the creation of nearly a direct line between the oropharynx and glottis in order for endotracheal tube placement. The line must be created by manipulation of the patient's airway by the operator with a laryngoscope. Due to poor operator and patient positioning in a helicopter, this process was hypothesized to be more difficult than HAVL, which allows the operator to pass an endotracheal tube around the natural curvature of the patient's upper airway. There are no studies to date comparing these two distinct techniques by board-certified emergency medicine physicians in a simulated mid-flight environment. Methods A single center, randomized crossover trial was performed using attending physician helicopter EMS providers in a simulated environment. After IRB approval and informed consent, physicians were randomized to perform five HAVL or SGVL intubations, followed by the subsequent technique. Intubations were performed in a grounded EC-135 helicopter with an AirsimTM airway management trainer restrained on the cot. Time to intubation (primary outcome) as well as first pass success (FPS) and Cormack-Lehane views were recorded for each attempt. Qualitative data was also obtained for physician preference and perceived difficulty. Results Fifteen physicians participated in the study. There was no statistically significant difference in time to intubation with HAVL versus SGVL (16.14 seconds vs. 16.12 seconds; p-value 0.97). FPS was 100% for both techniques. Ninety-seven percent of Cormack-Lehane views were grade one for HAVL versus 88% for SGVL. Despite no statistical significance in time to intubation, participants subjectively reported that SGVL required more physical force to perform intubation. The majority also qualitatively prefer HAVL over SGVL after performing the study for future flight intubations. Conclusions/Limitations Our results suggest that both SAVL and HAVL are efficacious techniques to perform intubations in an EC-135 helicopter, should this somewhat rare, but likely difficult procedure, be necessary. Providers did, however, prefer HAVL over SGVL in our group. The discordant quantitative and qualitative results in this study may be due to the static nature and highly favorable anatomy of a manikin, versus the varying anatomy of individual patients.

Laryngeal mask airway as a rescue device for failed endotracheal intubation during scene-to-hospital air transport of combat casualties.

Advanced airway management of combat casualties during scene-to-hospital air transport is challenging. Because of the short transport time, flight physicians of the Israeli military airborne combat evacuation unit are approved for the use of a laryngeal mask airway (LMA) in the event of failed endotracheal intubation (ETI). The aim of this study was to assess the effectiveness of LMA use during scene-to-hospital transport of combat casualties in Israel. A retrospective cohort analysis of all combat casualties treated with ETI during scene-to-hospital transport over a 3-year period was carried out. Successful LMA insertion was defined as satisfactory placement of the device on the basis of adequate chest expansion with bag-mask ventilation. The median flight time from scene to hospital was 13 min [interquartile range (IQR): 9-15 min]. Sixty-five casualties underwent ETI attempts, 47 successful and 18 failed. All 18 casualties who had failed ETI underwent LMA insertion as a rescue treatment. Six casualties suffered from traumatic brain injury, six had firearm injuries, two had blast injuries, and two had inhalational injuries. LMA insertion was successful in 16/18 (88.9%) casualties, 14 survived to hospital discharge, whereas two were declared dead upon hospital arrival. Two cases of LMA insertion were unsuccessful, but patients survived to hospital discharge. Among the 16 successful cases, the median oxygen saturation on scene-pickup before LMA insertion and on hospital-handover with LMA in place were 90% (IQR: 84-96%) and 98% (IQR: 96-99%), respectively (P<0.0001, the 95% confidence interval for difference between medians was 4-11). The findings of this study suggest that in the event of failed ETI, combat casualties can be treated effectively with LMA during a short scene-to-hospital transport time.

Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis

Introduction: Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. Methods: A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. Results: Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96–98) vs. 98% (95% CI 91–100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73–89) vs. 82% (95% CI 70–93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98–100) vs. 96% (95% CI 94–97) and first-pass success 89% (95% CI 77–98) vs. 71% (95% CI 57–84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88–100) vs. 98% (95% CI 95–100), but no analysis for physician ground first pass was possible. Conclusions: Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.

Compliance With a National Standard by Norwegian Helicopter Emergency Physicians

ObjectiveThe “National Standard Requirements for Helicopter Emergency Medicine Services Physicians” gives recommendations on medical requirements for flight physicians. This study describes the level of formal competence, experience, and guideline compliance of Norwegian helicopter emergency medical service (HEMS) physicians. MethodsIn May 2013, all HEMS physicians with full-time engagement at Norwegian HEMS bases were invited to participate in a cross-sectional survey using a structured, Web-based questionnaire. ResultsA total of 108 (79%) of 136 physicians replied to the survey, and all bases were represented. The majority (89%) had specialist training, and more than 60% had longer than 6 years of experience as a flight physician. Over 60% had attended trauma, pediatric, and incubator courses, and all physicians worked regularly in an anesthesia department. Most physicians were participating in simulation and procedure training. ConclusionMany of the basic requirements of the guidelines were met by HEMS physicians, but room exists for improvements. Norwegian HEMS physicians are experienced, but a need exists for a more structured curriculum in emergency medicine for HEMS physicians based on the broad spectrum of presented medical conditions to ensure optimal quality of care and safety for all patients in Norway.

The Astronaut-Athlete: Optimizing Human Performance in Space.

It is well known that long-duration spaceflight results in deconditioning of neuromuscular and cardiovascular systems, leading to a decline in physical fitness. On reloading in gravitational environments, reduced fitness (e.g., aerobic capacity, muscular strength, and endurance) could impair human performance, mission success, and crew safety. The level of fitness necessary for the performance of routine and off-nominal terrestrial mission tasks remains an unanswered and pressing question for scientists and flight physicians. To mitigate fitness loss during spaceflight, resistance and aerobic exercise are the most effective countermeasure available to astronauts. Currently, 2.5 h·d, 6-7 d·wk is allotted in crew schedules for exercise to be performed on highly specialized hardware on the International Space Station (ISS). Exercise hardware provides up to 273 kg of loading capability for resistance exercise, treadmill speeds between 0.44 and 5.5 m·s, and cycle workloads from 0 and 350 W. Compared to ISS missions, future missions beyond low earth orbit will likely be accomplished with less vehicle volume and power allocated for exercise hardware. Concomitant factors, such as diet and age, will also affect the physiologic responses to exercise training (e.g., anabolic resistance) in the space environment. Research into the potential optimization of exercise countermeasures through use of dietary supplementation, and pharmaceuticals may assist in reducing physiological deconditioning during long-duration spaceflight and have the potential to enhance performance of occupationally related astronaut tasks (e.g., extravehicular activity, habitat construction, equipment repairs, planetary exploration, and emergency response).

462: Air Medical Providers Accurately Prospectively Assess Airway Difficulty

Invasive airway management by endotracheal intubation (ETI) is frequently performed by air medical providers. Accurately predicting the difficulty of the procedure allows providers to have appropriate equipment available, and may improve patients' subsequent clinical course. Accurately estimating difficulty is especially important for air medical providers, as they perform ETI under less than ideal conditions, and have fewer resources available than in the hospital setting. The objective of this study is to determine how accurately air medical providers assess airway difficulty and to explore factors associated with under- and over-estimates of difficulty. Patients with advanced airway management performed by an air medical provider were enrolled in the Air Care Airway Registry from April 2004 to May 2007. The providers were flight registered nurses and flight physicians. Flight physicians were emergency medicine resident post-graduate year (PGY) 2-4, and attending emergency physicians. A PGY-1 emergency physician was present on some training flights. Prospective and retrospective airway difficulty was assessed by the air medical provider completing airway management. Difficulty was estimated on a 1 to 10 point scale, with 1 being easiest and 10 being most difficult. The difference between prospective and retrospective difficulty scores was calculated. Differences between means were assessed using student's t-test or analysis of variance (ANOVA). Pearson's correlation was used to assess the relationship between continuous variables. There were 179 patients in the registry; 3 did not have airway difficulty assessments recorded. The mean age of the 176 included patients was 38 (SD 22); 70% were male and mean weight was 81 kg (SD 28). The first medical provider attempting ETI was most commonly a PGY-2 physician (46%) or a flight nurse (30%), and ETI most often occurred in an ambulance (60%) prior to transport. Mean prospective difficulty was 5.0 (SD 2.5) and mean retrospective difficulty was 4.6 (SD 2.9). The majority of airways (73%) had an absolute difference between prospective and retrospective difficulty assessment ≤2. Factors associated with increasing difficulty were use of straight blade and decreased glottic exposure. Factors associated with decreasing difficulty were no suction needed, no backward upward rightward pressure (BURP) needed, and increased mouth opening (all p < 0.05). Air medical providers in this single center registry were accurate in the assessment of prospective airway difficulty: one quarter of cases examined had no change between prospective and retrospective assessments, and nearly three quarters had absolute difference between prospective and retrospective difficulty <2. Airways with a difficulty estimate that changed significantly from pre- to post-procedure shared characteristics that may not be readily apparent on initial visual assessment. While these factors were statistically associated with changes in airway difficulty assessments, the changes were small (<1.2 points) so effect on clinical course is unclear.

463: First-Attempt Success Rate of Endotracheal Intubation Performed by Air Medical Providers In Various Settings

Endotracheal intubation (ETI) in the air medical setting can be challenging, yet is commonly required of air medical providers. Understanding ETI failure rate and associated factors could improve training and increase ETI success rate in the air medical setting. We endeavored to calculate overall first-attempt success rates for air medical providers performing ETI in various settings and identify factors that may affect first-attempt success rate. Patients were enrolled in a prospective observational Air Care Airway Registry from January 2000 to March 2002, and from April 2004 to May 2007. Patients requiring advanced airway management performed by a member of the air medical flight crew (flight registered nurse and flight physician) were eligible for enrollment. The flight physician was most often an emergency medicine resident post-graduate year (PGY) 2-4, but on occasion was an attending emergency physician. An additional PGY-1 emergency physician was present on some flights. Cases were included in this analysis if the site where advanced airway management was performed, and the crew member performing the procedure, was recorded. The Chi Square or Fisher's Exact test was used to compare differences in categorical variables and Student's t-tests were used for continuous variables. From 305 patients enrolled, 291 patients were included in this analysis. Mean age was 36 (SD 21), mean weight was 79 kg (SD 27) and 70% were male. The first crew member attempting advanced airway management was most often a PGY-2 physician (51%) or a flight nurse (25%). The first advanced airway management attempt most often occurred in the ambulance (54%). Overall, the success rate of ETI on first attempt was 69.2% [95CI 62.3% to 73.3%]; 96.6% of patients were intubated in less than four attempts and there were up to 6 attempts in one case. Success on first attempt did not vary by provider type overall (p=0.076), or when ETI was attempted in an ambulance (p=0.392), at the scene (p=0.975), or in the helicopter (p=0.762). PGY-1 physicians were less likely to have first attempt success in an outside hospital (p=0.021). While the first attempt success rate appeared higher in a hospital setting, this did not reach significance (p=0.962), and there was no statistical evidence for differing success rates across the site of first attempt. Weight and age were not associated with initial intubation success. Males were more likely than females to require multiple airway management attempts (p =0.016). Table 1. First intubation attempt success rate by location.Tabled 1 The success of the first intubation attempt for air medical providers in this single center registry was similar to that found in other studies. The success rate appears consistent regardless of who attempts the procedure or where the attempt is made, although site and provider are not independent. Males required multiple intubation attempts more often than females; elucidating why this occurs requires further exploration of possible confounders.

Rapid Sequence Intubation (RSI) and Rapid Sequence Airway: An Airway911 Guide. 2nd ed. By Darren Braude, MD, EMT-P: Albuquerque (NM): Airway911; 192 pp, $50, ISBN 978-0-578-00903-2

In his preface, the author says, “All I ask from you is not to let this book sit on the shelf; the airway is just too damn important.” As an emergency and flight nurse for more than 15 years, I loved this book. It is a great resource for those in emergency, critical care, or transport nursing. Even if you are not the person actually performing the intubation or placing the advanced alternate airway, this book is a wonderful review of the critical measures associated with emergency airway management. This book was written by a paramedic who later became an emergency and flight physician. His mix of real-life prehospital and ED experiences is especially evident when the author describes past airway management adventures. Eight chapters make up this very user-friendly guide: (1) Introduction; (2) Basic Principles; (3) Pharmacology; (4) The Difficult and Missed Airway; (5) Pediatric Considerations; (6) The 10 P’s of Rapid Sequence Intubation; (7) Rapid Sequence Airway; and (8) Legal Stuff and Quality Assurance. Most chapters also include the author’s practical “take home points.” The author uses real-life case scenarios throughout the book to summarize the previously presented information. In addition, the majority of paragraphs have one or more icons to the reader as to Evidence-based medicine (self explanatory); caution (highlighting potential pitfalls); or key (author’s most important points.) One of the most helpful features I found was the use of “blue boxes” throughout the book. The author describes the information in these boxes as “Advanced, Controversial, or Otherwise Supplementary Material.” The information in these boxes is written in a question and answer format, with such questions as: “Why does it seem like everyone eats and drinks right before their accident?,” “Is it possible to suffocate someone with a bag-valve-mask?,” and “I’ve heard that Fentanyl does not cause hypotension, but I swear I’ve seen it. Is that possible?” These boxes are a great way to summarize the medication, procedure, and equipment controversies in a very short and sweet manner. The author provides a non-biased review of traditional and new-to-the-market airway toys, medications, and placement confirmation devices. In addition, the concept of rapid sequence intubation versus rapid sequence airway is discussed at length. Rapid sequence airway is a vital addition to the current airway management armamentarium as more and more prehospital and emergency/critical care settings are now embracing this concept. The book, with more than 100 sharp, full-color pictures, is written in a style that is very easy to understand, and more importantly, very easy to remember. It is almost as if you were sitting down and talking about airway management with an experienced mentor. In summary, this book is an invaluable resource to emergency, critical care, and transport professionals, all of whom should remember the American Lung Association’s current motto, “If you can’t breathe…Nothing else matters!” Scott DeBoer is Flight Nurse, University of Chicago Hospitals; Transport Nurse, Superior Ambulance Service; and Founder, Peds-R-Us Medical Education, Chicago, IL.

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.

Helicopter use in rural trauma

To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer. Intention-to-treat analysis using retrospective case note review of all helicopter emergency medical service trauma patients from January 2004 to November 2006. Global positioning system mapping technology was used to compare one-way road transfer times with two-way helicopter retrieval. Two hundred and twenty-two missions were identified from the helicopter log. Forty missions were aborted in flight. Of 182 patients transported, 11 records were incomplete, leaving 171 for analysis. Fifty (29%) patients transported had an Injury Severity Score (ISS) > 15; the average ISS was 12.30 (standard error of the mean 0.82). The average calculated distance flown was 160.4 nautical miles (standard error of the mean 5.29; range 28-360 nautical miles). There was no significant difference in ISS between ambulance officers and physician groups (t = -1.17, P = 0.25, 95% CI -7.37-1.91). There was no difference in the incidence of severe injury (ISS > 15, P = 0.39) or mortality (P = 0.33) when the groups were compared. Air transport was significantly faster beyond 100 km, with a mean difference of 48 min (P = 0.00). We could not identify a significant survival benefit attributable to the addition of a doctor, although numbers for this comparison were small. Predicting missions where flight physicians might provide benefit remain imprecise and should be a priority area for prospective evaluation. We have demonstrated that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care.

Einführungskurs „Ärzte in der Luftrettung” - Von der Idee zum Kurskonzept

Physicians who take a role as flight physicians in a Helicopter Emergency Medical System (HEMS) will encounter more frequently certain emergencies - such as multiple trauma, mass casualties etc. - compared to physicians in a ground based Emergency Medical System (EMS). Furthermore EMS teams already present on scene have a variance of expectations towards HEMS-Physicians. Therefore HEMS-Physicians not only must have the capabilities to treat patients properly, especially under difficult circumstances. Particularly with regard to leadership and Crew Resource Management (CRM) they will be demanded. Not least HEMS-Physicians need to have knowledge of safety and technical aspects of rescue helicopters and of operation tactics as well. Since there has been no uniform or standardised training for physicians, who will take a role in a HEMS, a course concept has been developed to improve and standardise the preparation for this challenging task.

Forum

Forum

High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost

BackgroundThis study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter.MethodsSeven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators.ResultsThe simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital.ConclusionIt is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.