Dr. Sunil Sookram MAvMed, MD, CCFP, FRCPC Clinical Professor Department of Emergency Medicine University of Alberta Medical Director: AHS IFS &

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1 Dr. Sunil Sookram MAvMed, MD, CCFP, FRCPC Clinical Professor Department of Emergency Medicine University of Alberta Medical Director: AHS IFS & Dispatch, STARS Grande Prairie

2 Objectives To showcase current Civil Aviation Medical Response Resources To highlight areas of physician involvement in Aeromedical Transport To explore how Retrieval Medicine has evolved in Canada.

physician involvement in Aeromedical Transport To

3 Today s Educational Journey 3 real clinical vignettes Case #1 Airline Role Case #2 Member of Transport Team Case #3 Quarterback of Patient Care

4 Case #1 Flying on a Malaysian Airlines flight B737 Hong Kong to KL Steward comes over to you about 2 hrs into flight (3.5 hrs) Have a sick patient in the back and wonder if you can help out and have a look.

5 Situational Awareness Flight Manifest contains titles (Dr.) Most airline flights have someone (Dr., Nurse, Paramedic) that has advanced medical training statistically Airlines have a medical kit and most have AED - even discount airlines North American Airlines and many international airlines subscribe to Medical Assist Companies that provide 24/7 online medical support (i.e. MedLink)

, Nurse, Paramedic) that has advanced medical training statistically Airlines have a medical kit

6 The Sequence of Events Patient assessed, while navigating medical kit patient starting vomiting and then suddenly arrested Cardiac arrest run on plane utilizing AED and ACLS drugs within medical kit help from travelling ICU Nurse and my wife Kit has limited Epi, bicarbonate, crystalloid fluid because of weight and size Need to liaise with pilot through flight attendants letting them know progress and medical needs. The Aircraft Commander (Captain) will make logistical and operational decisions on diversion based upon information provided.

bicarbonate, crystalloid fluid because of weight and size Need to liaise with pilot through flight attendants letting them know

7 Back to case Decision to divert was withheld as we were over the sea and 1.5 hrs to destination Rapid descent process employed to get us on the ground and can hurt ear drums and added vestibular issues of other passengers Very captive audience watched rescuscitation versus onboard entertainment system Work with aircrew to meet patient s immediate needs

ear drums and added vestibular issues of other passengers Very captive audience watched

9 Copyright/License Request permission to reuse Table 1. Study characteristics and incidence of in-flight medical emergencies. Authors Journal Dates Study Design Total # of Cases reported Incidence Diversion Cardiac Arrest/Death Hung et al Arch Int Med 01/2003 Retrospective 4068/5 Appx per 46 (1.1%) 30 (0.7%) /2008 Cohort, Single years billion revenue Airline-Hong passenger killometers Kong Sand et al Crit Care 01/2002 Retrospective 2 10,189/5 Appx. 14 (+2.3) per (0.5%) /2007 Airlines-Europe years billion revenue (2.7%) passenger kilometers Baltsezack, J Travel 01/2006 Retrospective 191/1 Not Analyzed Not 1 (0.5%) S Med /2007 Single Airline- Year Analyzed Asia Qureshi et E Med 06/2002 Retrospective 507/6 Not Analyzed Not Not Analyzed al Journal /2002 Single Airline- months Analyzed Edinburgh Delaune et Aviat Space 07/1999 Retrospective 2965/ per million (0.1 per al Environ Med 06/2000 single airline. year passengers (7.9%) million 2003 passengers). Dowdall, BMJ /1998 Retrospective 3386/1 Appx. 1 per 11,000 Not Not Analyzed Nigel 03/1999- Single Airline- year passengers Analyzed

7%) 2010 01/2008 Cohort, Single years billion revenue Airline-Hong passenger killometers Kong Sand et al Crit Care 01/2002 Retrospective 2 10,189/5 Appx. 14 (+2.3) per 279 52 (0.

10 Take Away Lessons for EM Physicians Be prepared Utilize the resources at hand (people, equipment, online support) Work with Aircraft Commander to make informed decisions factoring patient need and operational decisions

online support) Work with Aircraft Commander to make

11 Case #2 19 yo female drinking and driving. Car stuck lamp pole and drove front end of car posteriorly. Pt trapped in car for prolonged period. 2.5 hrs trying to extricate Remove vehicle from patient Due to lengthy period of entrapment, primarily 1 very trapped leg under dashboard, consideration of field amputation is made by on scene commander. Aeromedical crew sent out to transport. Physician accompaniment

5 hrs trying to extricate Remove vehicle from patient Due to lengthy period of entrapment, primarily 1

13 The Role of The Physician on Scene Limited Aeromedical crews highly trained and get enhanced training and experience compared to their ground based colleagues Role of Physician on on Mission: Master Triager (Disaster Scene) Advanced skills (USS, Central Line, Chest Tube, RSI) Unique situations (Obstetrics, field amputation)

Role of Physician on on Mission: Master Triager (Disaster Scene) Advanced skills

14 Strategic Medevac Interfacility Transfer Long Distance (transatlantic, transpacific), foreign countries Facilitates transfer of care (heterogenous medical capabilities around world) Bringing definitive care to patient on occasion Medical Diplomacy building bridges, field supervision, teachable moments for rural providers.

medical capabilities around world) Bringing definitive care to patient on

15 Case #3: Patient Quarterback ORNGE Transport Physician Consultant STARS Transport Physician BC Emergency Physician On line Support The Future of Physician On Line Medical Support for a Transport System

Emergency Physician On line Support The Future of

16 Air Ambulance Bases High Level Ft. Vermillion 10 Air Ambulances Bases 11 KA /7 High Level Ft. Vermillion Peace River (2 AC) Fort McMurray Slave Lake Grande Prairie Lac La Biche Edmonton Calgary Medicine Hat 3 STARS Bases Calgary Edmonton Grande Prairie Grande Prairie Ft. McMurray Peace River Alberta Slave Lake Edmonton Calgary Medicine Hat Lac La Biche

Vermillion Peace River (2 AC) Fort McMurray Slave Lake Grande Prairie Lac La Biche

17 Case #2 Nov 3 rd 2 calls occurring simultaneously Call #1 hypotensive, shocky 67 yr old female in Mayerthorpe with perforated viscus. Through Red Patient Referral Process. Dispatch STARS-3 and gave rescuscitation advice to local doctor. NG tube, fluids, Inotropic support, organized receiving surgeon Helicopter dispatched and call from Wainwright EMS requesting scene RV with STAR-3

Dispatch STARS-3 and gave rescuscitation advice to local doctor.

18 Initial Thoughts Cardiac Arrest dismal outcome, trauma arrest CAF member full court press Similar efforts for RCMP, Fire, EMS, public safety

20 ROSC of CAF mbr. Then What? STARS Helicopter too far north FW resources unable to land at Wainwright due to weather. Can only land in Lloydminster 1 hr away. Both patients need Critical Care Transport to Tertiary Care expeditiously Ground transport from Wainwright to Edmonton 2 hrs with very inexperienced ground crew. Physician accompaniment from Wainwright not possible.

Can only land in Lloydminster 1 hr away.

21 What Transpired Medical Care TP called Wainwright Hospital, spoke to local physician Appreciated that local physician needed help Called local GP Anesthesia, who came in to help manage patient

22 What Transpired Transport Medicine Operational Aspects No STARS, FW and Ground nonoptimum with current resources Called CFB Edmonton Base Hospital spoke to one of Flight Surgeons and he prepared to mobilize AE Team from ad hoc resources Called RCAF 408 THS Flight Ops rapid mobilization of Griffon with crew. FE reconfigured helicopter for Medevac Spoke to Flt Surg to bring appropriate AE kit Spoke to Wainwright Hospital to borrow ventilator, GP Anesthesia (was former Flt Surgeon)

23 Dispatched RCAF Helicopter to Wainwright Hospital with Ad Hoc AE team. Provided ongoing TP OLMC to Flt Surg en route outbound, and at scene to prepare patient, inbound leg via text Helipad at UAH needed to be secured and team prepared to receive at rooftop Called UAH ED and prepared team, spoke to Trauma Team to prepare through Charge Nurse

27 Extreme Example massaging the resources to meet the patient need Physician role is quarterbacking patient journey Active collaboration with Operational Coordinators to meet patient needs Active real time support to caregivers in the field with minimal time delay

28 Summary Physician as reluctant caregiver on commercial airliner Physician as active member of aeroretrieval team Physician as quarterback of patient transport journey

Alberta s Air Ambulance Service Delivery Model Improvements. Presented to Mackenzie County Municipality July 16, 2013

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