High performance team interaction in an air medical program

INTRODUCTION: The purpose of this qualitative study was to identify and describe the elements of a high performance team interaction on an air medical transport mission. METHODS: The phenomenologic method as described by Giorgi was used to guide data collection and analysis. Six flight nurses from around the United States were interviewed and audiotaped as they described their subjective perception of a high performance team experience. RESULTS: Four themes emerged from the data: collaboration, mutual respect and trust, fitness standards, and synergy. CONCLUSION: Implications for flight crews involved in this high performance environment may require attention to the identified themes to promote team performance.     

A survey of advanced trauma life support procedures being performed by physicians and nurses used on hospital aeromedical evacuation services

Traumatized patients may be transported by a variety of aeromedical transport teams. Frequently, the skills of physicians, nurses, and paramedical personnel overlap. This study was undertaken to determine if nurses used on hospital aeromedical evaluation services perform advanced trauma life support (ATLS) procedures usually reserved for physicians. Forty-seven hospital programs responded to our questionnaire. Flight nurses on programs (26) in which physicians were frequently used were significantly (p less than 0.05) less likely to perform cricothyreotomy, esophageal obturator airway placement, oral intubations, and pericardiocentesis than flight nurses of programs (21) not using flight physicians. Except for cervical tong placement (p less than 0.05), central line placement (p less than 0.05), and the performance of saphenous vein cutdown (p less than 0.05), no differences were found in procedures performed by flight nurses of programs not using physicians and those performed by flight physicians. We conclude that flight nurse abilities are expanding into areas traditionally set aside for physicians in providing advanced trauma life support procedures on hospital aeromedical services. Future studies need to be performed to determine their success and complication rates.     

Training of flight nurses on fixed-wing air ambulance services

Introduction: The purpose of this study was to determine the background of fixed-wing air ambulance nurses, what level of training they receive before assignment as a flight nurse, and how closely supervised these fixed-wing air ambulance programs are by their medical directors.

Methods: In 1993, a retrospective statistical questionnaire was sent to 113 fixed-wing air ambulance programs. Chief flight nurses for all 113 fixed-wing air ambulance transport companies were requested to complete a written survey consisting of 17 multiple choice and fill-in-the-blank questions about previous experience, flight nurse qualifications, and content covered in their initial training program.

Results: Of 113 surveys, 72 (64%) responded. The majority (87%) of the flight crew were 30 to 39 years of age. The crew mix is RN/EMT-P in 49%, RN/RN in 25%, and RN/RT in 25%. Experience before flying showed emergency department/intensive care unit in 87% with 13% specialized to a specific type of patient care. The initial training in classroom hours was less than 21 hours in 50% of programs. Training programs were taught by the chief flight nurse in 75%, the medical directors in 74%, and outside organizations in 30%. Fifty-five percent of programs use pilots or other flight crew members to supplement initial training. Only eight of the programs did not have yearly refresher classes. Programs providing more extensive training appear to be affiliated with hospital-based services. Medical directors were involved with the everyday running of air medical transports in 35 of the pro grams (50%), 20 medical directors (28%) did monthly chart reviews only, and 12 (17%) were not involved with their programs. There were three responses to “Other” and two with no responses.

Conclusions: Although fixed-wing flight nurses appear to be medically experienced personnel with previous intensive care unit or emergency department experience, this survey would suggest that fixed-wing flight programs are variable in the amount of initial training, level of instructors, ongoing medical education, and involvement of the medical director. This survey indicates the need for increased standardization of continuing education, as well as increased involvement of medical directorship in fixed-wing air ambulance services.     

Anxiety in adult fixed-wing air transport patients

INTRODUCTION: Critically ill patients may experience anxiety because of the method of transport, possibly having an impact on both patients and their health care providers. The purpose of this research was to study the presence and degree of anxiety in fixed-wing air transport patients. METHODS: Subjects were 41 patients 25 to 79 years of age. Self-ratings of anxiety were obtained and vital signs were recorded at five predesignated points before, during, and after the flight. Additional questions addressed current and previous experiences and perceptions of flying. RESULTS: Anxiety ratings were generally low, averaging approximately 1.9 on a 1 ("worry-free") to 10 ("completely terrified") scale. Anxiety was greatest in anticipation of the flight. Fourteen percent of patients had never flown before; patients with little or no flight experience had significantly higher anxiety ratings. However, in all cases anxiety declined steadily as the flight progressed. Most patients (82%) reported greater worry about their medical condition than about the flight. CONCLUSION: Anxiety is generally low among adult fixed-wing air transport patients and decreases further over time. This decrease was true even for patients who initially reported high levels of anxiety before the flight. The data suggest that previous flight experience can be used to predict anxiety during air medical transport.     

Origin of flight nursing in the United States Army Air Forces

The years of World War II mark the first extensive use of flight nurses in the United States military. These select flight nurses in the United States Army Air Forces during World War II, set the precedent for a unique field of nursing which has continued to the present day. This historical study traces the origin of flight nursing in the United States Army Air Forces from 1937, when the need for specially designated flight nurses could not be justified, until 1942, when flight nursing in the United States Army Air Forces became a reality.     

Is oral endotracheal intubation efficacy impaired in the helicopter environment?

INTRODUCTION: Patients transported by helicopter often require advanced airway management. The purpose of this study was to determine whether or not the in-flight environment of air medical transport in a BO-105 helicopter impairs the ability of flight nurses to perform oral endotracheal intubation. SETTING: The study was conducted in an MBB BO-105 helicopter. METHODS: Flight nurses performed three manikin intubations in each of the two study environments: on an emergency department stretcher and in-flight in the BO-105 helicopter. RESULTS: The mean time required for in-flight intubation (25.9 +/- 10.9 seconds) was significantly longer than the corresponding time (13.2 +/- 2.8 seconds) required for intubation in the control setting (ANOVA, F = 38.7, p < .001). All intubations performed in the control setting were placed correctly in the trachea; there were two (6.7%) esophageal intubations in the in-flight setting. The difference in appropriate endotracheal intubation between the two settings was not significant (chi 2 = 0.3; p > 0.05). CONCLUSION: Oral endotracheal intubation in the in-flight setting of the BO-105 helicopter takes approximately twice as long as intubation in a ground setting. The results support pre-flight intubation of patients who appear likely to require urgent intubation during air medical transport in the BO-105 helicopter.     

Air transport of patients with intracranial air: computer model of pressure effects

INTRODUCTION: Air is commonly trapped within the skull in patients who have been treated for trauma or intracranial hemorrhage. In Sweden, when such a patient is transported by air ambulance it is standard procedure to maintain sea-level pressure in the cabin to prevent increased intracranial pressure (ICP). However, this type of flight operation is more difficult and expensive. Maintenance of sea-level cabin pressure is not common practice all over the world, and the criteria supporting the choice of pressurization during transport are inadequate and in need of evaluation. The purpose of this study was to develop and evaluate a model to simulate the influence of intracranial air on ICP during air transport. METHODS: We identified an existing nonlinear model of the cerebral spinal fluid and intracranial pressure dynamics, then added intracranial air as a new component and evaluated the model through simulations. RESULTS: The model behaved as expected, and the simulations indicated that under normal flying conditions with decreased cabin pressure the initial intracranial air volume will increase by approximately 30% at normal maximum cabin altitude, 8000 ft. The increase in ICP depends upon both the initial air volume and the rate of change in cabin altitude. For an intracranial air volume of 30 ml the estimated worst-case increments of ICP from sea level to maximum altitude would be from 10 mm Hg to 21.0 mm Hg, or from 20 mm Hg to 31.8 mm Hg. DISCUSSION: Our results support the need for maintenance of sea-level pressure during air transport of patients with suspected intracranial air, since an ICP increment could potentially impair the patient's clinical condition.