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.

Storage Age of RBCs Transfused by a Prehospital Patient Transport Program vs the Hospital Emergency Department.

Recently published data suggest that transfusion of RBCs stored for 22 days or longer was associated with increased mortality among massively transfused trauma patients. We performed a 24-month retrospective review of medical transport service transfusion records and a 2-month, overlapping review of transfusions of uncrossmatched RBCs in the emergency department. RBC units issued to the transport program were older than RBC units issued to the emergency department trauma refrigerator (10.6 vs 8.7 days, P < .001). Similarly, RBC units were older at the time of transfusion during transport compared with the emergency department (20.3 vs 14.3 days, P < .001). Transport programs and blood banks should jointly review their RBC inventory management programs. Issuing RBCs to a medical transport program is a logistical challenge that, unless actively managed, may not ensure access to blood that is as fresh as blood in the emergency department.

Establishing Transport Statistics: Results From the Medevac Transport Statistics Survey

ObjectiveThe purpose of this article was to report the results of a national survey of medical transport programs to establish national estimates of critical care transports and use those results combined with other data sources to generate annual transport volume estimates. MethodsAn online survey was administered to collect transport statistics from medical transport programs registered in the Association of Air Medical Services Atlas and Database of Air Medical services in 2015. ResultsRoughly 20% of all registered programs participated. An estimated 640,000 critical care transports are conducted annually; an additional breakdown by mode of transfer is presented. ConclusionLow participation rates preclude establishing precise critical care transport statistics. Future participation is encouraged to enable more accurate data reporting to establish resources that can support research and policy initiatives.

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.

What Is a Medical Transport Program?

When the Commission on Accreditation of Medical Transport Systems (CAMTS) started in the early 1990s, we were accustomed to a hospital-based program with one or two helicopters based at a hospital and contracting with an aviation vendor to supply the aircraft, pilots, and maintenance. Those days are long over. We are now seeing more business arrangements than we can possibly comprehend or begin to put into a category of a single medical transport program. We see approximately 10 “report of changes” in the currently accredited services each quarter, and by the time we receive a program information form from a new program, there have been so many changes in the way they originally did business that we can barely recognize the program that submitted their one-page application.

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.

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.

CAMTS graduates new site surveyors

In 2004, the Commission on Accreditation of Medical Transport Systems (CAMTS) had 28 active site surveyors. Assigning 2 surveyors for most of the 53 site visits completed in 2004, however, resulted in very restrictive scheduling. The Site Surveyor Selection Committee, headed by coordinator Karen Rogers, began reviewing applications for surveyor positions in April 2004. Of 57 total applicants, 33 qualified and were interviewed by board members and current surveyors. In November 2004, 19 applicants were selected to attend the site surveyor training class in January 2005. The surveyor selection process requires each candidate to complete an application, submit a letter of introduction and curriculum vitae, and provide 2 written references. Site surveyors are chosen very carefully, not only for their qualifications and level of experience but also for the geographic region and area of expertise they represent based on the needs of CAMTS at the time. Because the types of programs that apply for accreditation vary widely, CAMTS tries to match the surveyors' backgrounds with the types of services offered by the programs. All applicants must have a minimum of 4 years of experience in medical transport as a patient care provider, pilot or mechanic, communications specialist, or manager. Management experience is very important, as is service with more than 1 medical transport program. Ultimately, the interview process tells us a great deal about the applicant's interview style, posture, eye contact, and basic demeanor, which are important qualities for a site surveyor. In fact, “Image of a Site Surveyor” is one of the topics taught during the 3-day class. This topic includes behavioral expectations and how to present and encourage open communications. Other topics include a detailed description of current CAMTS standards and policies. The class also includes reviewing a fictional medical transport program with a Power Point tour and role-playing interviews. Attendees are separated into survey teams that interview faculty who are in their roles as program director, lead pilot, medical director, chief flight nurse, etc. The tour and interviews mimic an actual site visit, including the closing conference, and provide the faculty with an opportunity to present some of the unique situations encountered by our site surveyors over the past 10 years. On the last day of class, the teams present to the full class and faculty their findings from interviews and reviews of the program information form. Applicants are required to attend this class before they conduct their first site visit with a senior site surveyor. We anticipate completing more than 60 site visits in 2005, and the following people are welcome additions to our prestigious list of CAMTS surveyors: Cameron Bell, EMT-P, Calgary, Canada Sheila Calvert, RRT, Dallas, TX Donna York Clark, RN, Lebanon, NH Jan Eichel, RN, Kalamazoo, MI Jon Gryniuk, EMT-P, Albany, NY Dan Hankins, MD, Rochester, MN Patti Klein, RN, St. Louis, MO Peter Martin, MD, Pittsburgh, PA Ken Matthews, RN, Salt Lake City, UT Rick Morley, Pilot, Kalamazoo, MI Becky Ross, RN, Greenville, NC Shirley Scholz, RN, Lubbock, TX Jason Schwebach, Pilot, Charlotte, NC Charlann Staab, RN, Phoenix, AZ Denise Treadwell, RN, Birmingham, AL Ron Walter, EMT-P, Pittsburgh, PA Lisa Weaver, EMT-P, Dayton, OH Jack Wells, MD, Columbia, MO

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?