INDICATIONS FOR AIR TRANSPORT, INTERCEPT GUIDELINES, AND OTHER CONSIDERATIONS MARC CRESWELL, OPERATIONS MANAGER AIR MED SERVICES, LLC

Transcription

1 INDICATIONS FOR AIR TRANSPORT, INTERCEPT GUIDELINES, AND OTHER CONSIDERATIONS MARC CRESWELL, OPERATIONS MANAGER AIR MED SERVICES, LLC

2 Objec&ves History of Helicopter Air Ambulances Indica&ons for transport a pa&ent by Helicopter Air Ambulances Proper use of Helicopter Air Ambulances Intercepts In the field At a ter&ary care hospital not considered defini&ve care Other considera&ons Loading &mes Distances Safety

3 History First pa&ents we moved by hot air balloon during Franco Prussian War in 1870 US Army built a plane to move casual&es in 1910, it crashed, delayed development un&l WWI In 1917 a plane moved a pa&ent in Turkey, 45 minutes by air, 3 days by ground Royal Doctor Service in Australia started in 1928, made 50 flights in first year, moved 225 pa&ents

4 History Korean War pioneered Helicopter EMS, death rate dropped from 4.5 to 2.5 per 100 In Vietnam, the Huey dropped the death rate to 1 in 100 Military Assistance to Safety and Traffic system, was established in San Antonio in 1969 CARESOM was established in Mississippi in 1969.

5 History Nov. 1, 1970, the first air ambulance helicopter, Christoph 1, entered service Munich, Germany. Flight For Life began in 1972 with an Aloue^e III, in Denver, Colorado Hermann Life Flight began opera&on in Houston in 1976 by Dr. Red Duke

6 History Sept. 1, 1981, Air Med Services launched in Lafaye^e, La. By 1998, Air Med was flying a fleet of 8 helicopters and 5 fixed wing airplanes Air Med Services now flies a fleet of six EC- 135s and 7 fixed wing airplanes to include the Lear 45 Air Med launches 8500 &mes per year, transports 2500 pa&ents and 5000 passengers yearly

7 Types of missions Community Based not a^ached to a hospital and generally respond to all request Hospital Based sponsored by a hospital, missions are usually in house request only Hybrid Service a mix of different services, some hospital affilia&on, some community support

8 Types of helicopters Light Single Engine single engine, fly in fair weather, single pa&ent, 2 a^endant, single pilot, generally community based, but some hospital use, $2- $4 million acquisi&on costs Light Twin Engine twin engine, two pa&ents, single or dual pilot flown in compromised weather using instruments, $6- $9 million cost Medium Twin Engine dual pilot, instrument flight, mul& pa&ent, mul&ple team members, $10- $18 million cost

9 Currently * Currently, there are est helicopter air ambulances in the US, and 150 fixed wing air ambulances, employing 40,000 people * Es&mates that 300, ,000 pa&ents are transported annually * $4- $5 billion dollar industry *From 2011 through 2013, there were seven air ambulance accidents resul&ng in 19 fatali&es and seven commercial helicopter accidents that claimed 20 lives. * The industry is being changed by government regula&on to enhance safety * Helicopter equipment such as NVGs, EGPWS, TAWS are being mandated * Increased Risk Assessment tools, increased surveillance of large operators, opera&onal control centers

10 NAEMSP recommended indica&ons for air transport, Trauma The pa&ent has a serious injury either based on triage criteria or mechanism of injury or ransporta&on by ground ambulance is difficult or prolonged. Pa&ents mee&ng triage criteria for evalua&on at a trauma center: Trauma Score < 12, Glasgow Coma Score < 10, adult with systolic blood pressure < 90 mm Hg or respiratory rate < 10 or > 35 breaths per minute or heart rate < 60 or > 120 per minute Mechanism of injury: (1) vehicle roll- over with unbelted passengers (2) pedestrian struck by a vehicle traveling > 10 miles per hour (3) fall > 15 feet (4) motorcycle rider ejected at > 20 miles per hour penetra&ng trauma to head, neck, chest, abdomen or pelvis (5) mul&ple vic&ms present spinal cord or spinal column injury producing paralysis par&al or total amputa&on of an extremity (excluding toes and fingers) two or more long bone fractures, major pelvic fracture crushing injuries of head, chest or abdomen major burns especially with inhala&on injury major chemical or electrical burns serious trauma&c injury and pa&ent < 12 years of age or > 55 years of age near drowning with or without hypothermia Difficult ground access: (1) wilderness rescue (2) ambulance unable to reach or leave site due to weather, road condi&ons or traffic Long or distant ground transporta&on: (1) &me to trauma center by ground > 15 minutes (2) &me required to transport by ambulance to nearest medical facility is greater than the &me to ship by air to a trauma center (3) &me required to extricate pa&ent > 20 minutes (4) no other medical transport available to the community if the ambulance is gone for an extended period of &me (5) local ambulance out of service or unable to deliver advanced life support

11 NAEMSP recommended indica&ons for air transport, Medical i. Pre transport cardiac/respiratory arrest ii. Requirement for con&nuous intravenous vasoac&ve medica&ons or mechanical ventricular assist to maintain stable cardiac output iii. Risk for airway deteriora&on (e.g., angioedema, epiglom&s) iv. Acute pulmonary failure and/or requirement for sophis&cated pulmonary intensive care (e.g., inversera&o ven&la&on) during transport v. Severe poisoning or overdose requiring specialized toxicology services Urgent need for hyperbaric oxygen therapy (e.g., vascular gas embolism, necro&zing infec&ous process, carbon monoxide toxicity) vii. Requirement for emergent dialysis viii. Gastrointes&nal hemorrhages with hemodynamic compromise ix. Surgical emergencies such as fascii&s, aor&c dissec&on or aneurysm, or extremity ischemia x. Pediatric pa&ents for whom referring facili&es cannot provide required evalua&on and/or therapy

12 More realis&c indica&ons for air transport *when a 0me saving will be realized that will benefit the pa0ent. All pa&ents mee&ng LERN Trauma Criteria Inclusive of Vital Sign Criteria, Anatomical Findings, MOI and Special Considera&on Pa&ents All Pa&ents mee&ng LERN Stroke/STEMI Criteria Other pa&ents who have obvious need for rapid assessment/ stabiliza&on in an ER/ED Any pa&ent in an MCI When local ambulance coverage will be compromised

13 LERN Exclusion Criteria Unmanagable Airway Trauma&c Arrest Tension Pneumo Burns > 40% w/o IV Burns that require airway and none established

14 LERN Entry Criteria GCS 13 VS/Anatomical Findings SBP <90mmHg RR <10 or >29 breaths per minute All penetra&ng injuries to head, neck, torso, and extremi&es proximal to elbow or knee Chest wall instability or deformity (e.g. flail chest) Two or more proximal long- bone fractures Crushed, degloved, mangled, or pulseless extremity Amputa&on proximal to wrist or ankle Pelvic fractures Open or depressed skull fracture Paralysis Fractures with neurovascular compromise

15 LERN Entry Criteria MOI Findings Falls - - Adults: >20 feet (one story is equal to 10 feet) - - Children: >10 feet or two or three &mes the height of the child High- risk auto crash - - Intrusion, including roof: > 12 inches occupant site; > 18 inches any site - - Ejec&on (par&al or complete) from automobile - - Death in the same passenger compartment - - Vehicle telemetry data consistent with a high risk of injury Auto vs. pedestrian/bicyclist/atv thrown, run over, or with significant (>20 mph) impact Motorcycle crash >20mph

16 More realis&c indica&ons for air transport *when a 0me saving will be realized that will benefit the pa0ent. All Pa&ents mee&ng LERN STEMI Criteria

17 More realis&c indica&ons for air transport *when a 0me saving will be realized that will benefit the pa0ent. All Pa&ents mee&ng LERN Stroke Criteria

18 Other Pa&ents who could benefit from air ambulance transport Burns requiring entry into burn unit Cardiogenic shock Anaphylaxis Overdose Post syncopal episode Electrical injuries GI Bleeding Other modali&es not listed IAD Firing Post Cardiac Arrest ROSC Pulmonary Failure Electrical injuries Pre- eclampsia/eclampsia New Onset Seizures

19 Pa&ents who do not meet indica&ons or that may be contraindicated for air transport Extremes in size or weight Claustrophobic or extreme fear of flying Inability to lie flat Pa&ents not needing immediate access to an ER with minor complaints except in MCI or lack of ambulance coverage Recovered hypoglycemia Isolated sor &ssue trauma Psychiatric pa&ents who may pose a danger to the flight crew Pa&ents who have injuries that require management but cannot be accessed in the helicopter. When a &me savings will not be realized

20 U&lizing Air Ambulances Generally speaking, 911 centers may not have enough info to determine air ambulance u&liza&on Auto Launch can save &me, this means launching the air ambulance before the ambulances arrive on scene You may request an Air Ambulance as needed, as long as you consider the flight &me to your loca&on, the &me spent loading and deciding if it will save &me. Fire, police or other agencies may request an Air Ambulance Once you arrive on scene, size up the situa&on and advise ASAP if the air ambulance is needed

21 U&lizing Helicopter Air Ambulances Do not wait on scene for an air ambulance if you are ready to transport. Determine the ETA of the air ambulance and decide if wai&ng will save &me. Coordina&on via radio is vital to making this decision

22 Selec&ng a Landing Zone 1 st Choice - As close as safely possible to incident Benefit - shortest transport &me 2 nd Choice - Between route to the hospital and incident Benefit - on the way to the hospital, not further away, slight delay 3 rd Choice predesignated area, i.e.. football field Downside - ambulance has to load, then unload, helicopter has to land away from incident, can cause major delay

23 Landing Zones During the day: o A high and low recon will take 2-3 minutes o No need for a formal LZ set up o GPS coordinates are good for finding the area o If using a roadway, both direc&on of travel should be blocked o The LZ should be accessible to the ground crew to be able to carry the pa&ent to the aircrar o An area of 75 X 75 is sufficient without debris, tall trees, livestock, or crowds This is too small

24 Landing Zones should be free from debris

25 Landing Zones on roadways should be secure

26 Night Landing Zones o A formal LZ set up by trained NLZ Coordinators is required o A night landing can take 4-5 minutes o A thorough recon of both the airspace and the ground area is required o Direct Ground to Air communica&ons are required o GPS coordinates are good for finding the area o If using a roadway, both direc&on of travel should be blocked o The LZ should be accessible to the ground crew to be able to carry the pa&ent to the aircrar o An area of 100 X 100 is the minimum without debris, tall trees, livestock, or crowds

27 No object higher than No object higher than Departure Zone 100ft Touch Down Zone 100ft Approach Zone B No object higher than ft Approach Zone A ft WIND DIRECTION

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29 Assessment &me In a best case scenario, the flight crew will asses and prepare the pt. for a short period You can speed this up by having this info C/C ABCDE s HPE SAMPLE What have you done? Has he go^en be^er? Where does he want to go?

30 Cold Load &me The pt. must be loaded onto flight stretcher, secured and carried to the helicopter 2-3 minutes The pt must be loaded into the helicopter. 1 minute The pt. must be secured for flight 1 minute The helicopter must be started and brought into flight 4-6 minutes Best case scenario, 8 9 minutes

31 Hot Load &me The pt. must be loaded onto flight stretcher, secured and carried to the helicopter 2-3 minutes The pt must be loaded into the helicopter. 1 minute The pt. must be secured for flight 1 minute Best case scenario, 4-5 minutes

32 Hot Loading an Air Ambulance The more info you give us The closer you are to the landing area The more the pt is packaged and ready The more likely the flight crew can communicate to the pilot that a HOT LOAD is expected

33 Loading an Air Ambulance Side loading loads from side, usually using sled type stretcher Rear loading loads from rear, using wheeled stretcher, exposure to tail area

34 Hot Loading an Air Ambulance Only approach running helos arer OK from flight crew and only from the sides, no need to squat, but slight stooping is recommended Exposure to tail area should be avoided, items that can become airborne should be secured

35 Hot Loading an Air Ambulance Bring the pa&ent and not the ambulance to the helicopter, keep vehicles far away Antennae strikes This could have been a fatal incident

36 Intercepts Generally done anywhere a helicopter can land Except at night, then at hospital helipad or other predesignated site Trying to get a NLZ set up while doing an intercept almost always waste &me Intercepts should be in the direc&on of the defini&ve care hospital, not away

37 Intercepts Tertiary care hospital Scene X Intercept Definitive Care Hospital 15 miles 40 Miles

38 Common Intercept Points Football or Soccer fields Parking Lots Airports Highway intersec&ons All are acceptable if in the direction of the hospital

39 Primary Care Hospital Intercepts Call hospital and advise, Should be ground level helipad Decisions based on pa&ent condi&on, enter hospital or wait You must go inside for Uncontrolled airway Cardiac arrest Tension Pneumo If staff makes contact or treats pt. cons&tutes EMTLA issue

40 SituaEonal and Time Awareness Tunnel vision accounts for most issues Stop and think, will I save any &me Stopping and unloading stops momentum, there is a change in provider, there is limited informa&on

41 Unload Time Once the helicopter has landed 30 seconds to 2 minutes to cool down and stop 1 minute unloaded 5-10 minutes gemng from helicopter into the ER