Influence of the helicopter environment on patient care capabilities: flight crew perceptions

INTRODUCTION: Flight crew perceptions of the effect of the rotary-wing environment on patient-care capabilities have not been subject to statistical analysis. We hypothesized that flight crew members perceived significant difficulties in performing patient-care tasks during air medical transport. METHODS: A survey was distributed to a convenience sample of flight crew members from 20 flight programs. Respondents were asked to compare the difficulty of performing patient-care tasks in rotary-wing and standard (emergency department or intensive care unit) settings. Demographic data collected on respondents included years of flight experience, flights per month, crew duty position and primary aircraft in which the respondent worked. Statistical analysis was performed as appropriate using Student's t-test, type III sum of squares, and analysis of variance. Alpha was defined as p < 0.05. RESULTS: Fifty-five percent of programs (90 individuals) responded. All tasks were significantly rated more difficult in the rotary-wing environment. Ratings were not significantly correlated with flight experience, duty position, flights per month or aircraft used. CONCLUSIONS: We conclude that the performance of patient-care tasks are perceived by air medical flight crew to be significantly more difficult during rotary-wing air medical transport than in hospital settings.     

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.     

Presumption of death by air medical transport teams

BACKGROUND: The purpose of this study was to investigate nationwide trends and factors influencing the determination of death practice by rotor-wing air medical transport programs. METHODS: A survey was mailed to all Association of Air Medical Service members concerning demographics, crew configuration, team leader, patient population, field death determination protocols, and other possible associated factors. All rotor-wing air medical transport programs that carry out scene transports were included. RESULTS: The most common field presumption criteria were no response to advanced cardiac life support (77%), no signs of life on scene (65%), and asystole in 2 EKG monitor leads (61%). The most frequent reasons cited not to presume a patient dead in the field were political issues (71%) and signs of life on scene (56%). Criteria other than medical condition that were considered in the decision to presume death were ground personnel input (55%) and program policy/medical control (39%). The following factors did not significantly affect the presumption rate: crew configuration, team leader, transport time, billing, and type of medical control. CONCLUSION: Medical criteria appear to determine presumption of death in the field. Nonmedical factors, such as billing, response, and transport times, do not affect this process.     

The effect of an in-flight, emergency training program on crew confidence

INTRODUCTION: Despite some progress, the air medical transport profession continues to experience widely publicized accidents that result in injuries and death to crew members and patients. An air medical crew member's experience, training and confidence may affect his or her ability to deal effectively with an in-flight emergency, and may also affect his or her behavior before and after the emergency. SETTING: A hospital-based, rural rotor- and fixed-wing program flying approximately 890 flights per year. Seventy-seven percent of these flights are interfacility. METHODS: A pretraining survey evaluated the experiences of air medical crew members and pilots. A 20-question assessment tool based on a 5-point Likert scale evaluated how confident the individuals were in their ability to react to in-flight emergencies. An extensive in-flight emergency training program was then conducted. Personnel were asked to complete the same questionnaire one month and six months after the training. RESULTS: On the pretraining questionnaire, flight crew members with neither prior training nor actual experience in in-flight emergencies showed the lowest level of confidence. Those with prior training, actual in-flight emergency experience or both, responded with higher levels of confidence. The mean confidence scores of the study participants increased from 82 pretraining to 89 at one month post-training and remained at the increased level six months after training. CONCLUSIONS: A training program focusing on in-flight, aircraft-related emergencies can increase the crew's confidence during such situations. This increase in confidence is most noticeable in those without previous training or experience and is maintained for at least six months. Several other benefits occur from the training program.     

Analysis of patients discharged from receiving hospitals within 24 hours of air medical transport

Introduction: Use review has become increasingly important in the current atmosphere of cost justification for air medical transport. One criterion for use review is patient discharge from receiving hospitals within 24 hours of transport. The objective of this study was to determine the frequency and characteristics of patients discharged within 24 hours of air transport; the goal was to identify particular patient types likely to be discharged soon after air transport.Methods: Flight records from November 1994 to September 1995 were reviewed. Follow-up identified patients who were discharged within 24 hours of air medical transport; these were designated the “24-hour group.” Other patients were designated the “overall group.” Comparisons between groups were made using the t test, Wilcoxon rank sum, and chi-square analysis (α = 0.05) for the following factors: age, vital signs, Glasgow coma score, percentage of intubated patients, and percentage of trauma and scene transports.Results: Of the 945 flights analyzed, 42 (4.4%) transported patients who were discharged within 24 hours of air transport. Patients in the 24-hour group were younger, less likely to be intubated, and more likely to be scene-trauma transports compared with the overall group.Conclusion: This study demonstrates that air medical transports meet currently accepted criteria for helicopter transport. This study suggests that inappropriate air medical transport is rare, even in patients discharged from receiving hospitals within 24 hours of air transport.     

Contribution of air medical personnel to the airway management of injured patients

INTRODUCTION: Air medical services are being pressured to demonstrate their value. Airway management is the first priority of care when treating injured patients in the prehospital setting. Injured patients with decreased Glasgow Coma Scale (GCS) are candidates for advanced airway procedures and air medical transport. RESEARCH QUESTION: The purpose of this study was to determine the extent of air medical crews' contributions to the airway management of the injured patient in the prehospital setting. METHOD: A study of adult (age > 12 years) injured patients encountered in a field setting, whose GCS on the arrival of the air medical crew was < or = 8, was conducted for 21 months (Feb. 1, 1991-Oct. 31, 1992). RESULTS: During the study period, 174 patients who met the criteria were transported by the air medical crew. All but one received advanced airways including oral tracheal intubation, nasal tracheal intubation or cricothyrotomy. Of those, 68 (39%) of these procedures were completed by ground personnel (ground group), and 105 (61%) were completed by the air medical personnel (air group). The mean GCS for the ground group was 3.69 and for the air group was 4.69. The distributions were significantly different (Wilcoxon Rank Test p = 0.0002). Nineteen percent (13/68) of the patients whose airways were successfully managed by the ground personnel had a GCS of 5 to 8, as did 44% (46/105) of the air group's patients. The groups' patients were not significantly different in age or sex distribution. CONCLUSION: Properly trained air medical personnel positively contribute to the prehospital care of injured patients by establishing definitive airways in patients with higher GCSs.     

Characteristics of patients transported by an aeromedical service for acute toxicologic emergencies: a 5-year experience

INTRODUCTION: Aeromedical services are used routinely in the prehospital and interhospital transfer of patients with trauma, neurosurgical, cardiac, and other conditions requiring specialized care. The use of aeromedical transport in patients with acute toxicologic emergencies is not well described. We sought to investigate and describe the characteristics of patients transported by our aeromedical service. SETTING: The study was performed at an urban critical care transport service operating both ground and aeromedical units and transporting an average of 3,362 patients per year during the study period. METHODS: Charts from the 5-year period of 2000 to 2004 for which a toxicologic emergency was coded as the primary diagnosis were identified and reviewed by the authors. Data abstracted included age, sex, toxin(s) involved, treatment rendered at the scene/bedside and en route by the transport team, and additional data (electrocardiogram [ECG] findings, serum levels) when appropriate. RESULTS: One hundred thirty-three patients were transported (for a total of 135 transports). Most (82%) were transported by air. Carbon monoxide was the most common toxic exposure, accounting for 16% of all transports. Fifty-seven percent of the patients were intubated, with 11% intubated by the flight crew. Antidotes were administered in 40 patients, with naloxone and bicarbonate being the most common. CONCLUSION: Acute toxicologic emergencies accounted for a small percentage of total transports. The most common additional intervention by flight crews was endotracheal intubation. Identification of common poisonings encountered by flight crews may assist services in developing education and quality assurance programs.     

Monitoring the appropriateness of air medical transports

INTRODUCTION: With pending changes in the health-care system, there are increasing pressures for each aspect of health care to justify its use. Several organizations, including the Association of Air Medical Services (AAMS), have published position papers listing appropriate indications for air medical services. Additionally, the Commission on Accreditation of Air Medical Services (CAAMS) specifies that air medical services monitor their flights for appropriateness. The purpose of this study was to determine how often the air medical transports by this program met at least one of the AAMS criteria. METHOD: The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added. Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record. RESULTS: During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria. CONCLUSION: The AAMS "Appropriate Use of Air Medical Services" position paper provides a foundation to monitor the utilization of an air medical transport program, which can be used to meet both government payer requirements for justification and the CAAMS requirement for utilization review.     

EMS provider level does not impact use of air medical transport

INTRODUCTION: The local emergency medical services (EMS) provider level within a nearby EMS system changed from EMT-I to paramedic. This increase in level of care was expected to decrease utilization of air medical transport and increase acuity of patients flown. SETTING: Semirural, mountainous area with an annual volume of 2800 transports. METHODS: Retrospective review of the EMS database performed for the 24-month period before and after the change in local provider level. The number and acuity of patients flown was recorded. Data analysis was performed using chi-square with significance at P <.05. RESULTS: A total of 53 flights with an EMS call volume of 2544 were flown in the 24-month period before the change in EMS provider level, and 54 flights with a call volume of 2842 in the following 24-month period (P >.05). The number of patients with abnormal vital signs or injury severity markers was not different between the 2 periods (P >.05). CONCLUSION: The change in EMS provider level from EMT-I to paramedic in this semirural area had no impact on the number of air medical transports. The acuity of patients flown after the change in EMS provider level remained similar based on common hemodynamic and injury severity markers.     

Flight crew physical fitness: a baseline analysis

INTRODUCTION: The purpose of this pilot study was to determine whether flight crew personnel are physically fit in comparison to published standards for the average American adult. SETTING: The study group consisted of pilots, paramedics and nurses in two similarly configured and geographically located rotor-wing air medical transport programs. METHODS: A physical fitness assessment of flight crew members was conducted. The results were compared with published standards for average adult males and females (AVG). Percentage of fat in body composition (FM%), aerobic fitness (VO2MAX), muscular endurance (ME), muscular strength (MS) and flexibility (FL) measurements were obtained using accepted testing methods. RESULTS: The study population consisted of 29 male and 21 female individuals. The following were their mean scores. Males averaged: pFAT = 19% (AVG = 20.0%); VO2MAX = 41.0 (AVG = 42.5); ME = 37.0 (AVG = 28.5); MS = 125.0 (AVG = 86.5); FL = 5.2 (AVG = 1.4); Females averaged: pFAT = 28.0% (AVG = 26.5%); VO2MAX (AVG = 34.0); ME = 27.0 (AVG = 21.0); MS = 83.0 (AVG = 76.5); FL = 4.5 (AVG = 3.4). CONCLUSION: These baseline data suggest the study population of air medical flight crew was physically fit compared to the average American adult.     

Helicopter dispatch: a time study

PURPOSE: To quantitate request to liftoff (R/L) and dispatch to liftoff (D/L) times and reasons for delay in an active air medical transport program. METHOD: This was a prospective observational study blinded to crew and pilots. Data were collected by the communications department during a 4-week period on 197 consecutive missions. RESULTS: The air medical helicopter program services 25,000 square miles with four BK 117 helicopter each staffed by nurse/paramedic crew. During the study period, R/L and D/L averaged 10.9 and 6.8 minutes, respectively. One hundred and twenty-two flights had an R/L of 10 minutes or less for an average R/L of 7.2 minutes and D/L of 5.9 minutes. Seventy-five flights had an R/L greater than 10 minutes, for which reasons included weather check--21; standby by requestor--27; all ships in flight--5; receiving facility delay--4; mechanical problems--4; original ship diverted--2; additional fuel needed--1; airport clearance--1; and no specific reason given--10. CONCLUSION: Most variance occurred in R/L rather than D/L. Evaluating R/L time not only provides a better indication of program activity but also identifies most delays. It appears reasons for delay are limited, which should allow development of a concise plan to overcome them.     

Safety of long distance aeromedical transport of the cardiac patient: a retrospective study

BACKGROUND: The purpose of this study is to provide data regarding the safety of long distance air transport of cardiac patients, establish a time frame for safe transport, and assess current guidelines for postmyocardial infarct (post-MI) transport. METHODS: Retrospective analysis of all long distance aeromedical transports performed by Montreal-based Skyservice Lifeguard from January 1 to October 1, 1998. RESULTS: 109 cardiac patients were transported; 83 by air ambulance (AA), and 26 commercially (C). Diagnoses included MI (63%), unstable angina (31%), congestive heart failure (21%), and arrhythmia (17%). Patients were transported a mean of 7 d (AA) vs. 13.7 d (C) after presentation. Inflight complications, occurring in 10% of AA and 4% of C flights, were minor (chest pain, desaturation, and hypotension), and resolved quickly. In 51 post-MI AA patients, complication rate for transport > 7 d after admission was 0% (vs. 14% <7 d), and > 72 h after last chest pain was 6% (vs. 18% <72 h). Comparing uncomplicated (n = 25) vs. complicated (n = 26) MI reveals fewer complications for transport 0-3 d (13% vs. 50%) and 4-7 d (9% vs. 14%) after admission, and 48-72 h after last chest pain (0% vs. 100%). CONCLUSIONS: AA transport of cardiac patients can safely be performed earlier than guidelines for C flights. AA transport appears safe after complicated MI by day 7 or > 72 h chest pain free, and after uncomplicated MI by day 3 or > 48 h chest pain free. Future guidelines for aeromedical transport post-MI should distinguish between C and AA.     

When is air medical service faster than ground transportation?

The purpose of this study was to mathematically define a distance or travel-time interval in which air medical evacuation would benefit the patient more than ground transport. The authors derived mathematical formulas from known variables (ground travel, extrication and rendezvous times) and fixed averages (on-scene time, lift-off time, and speeds) and used those formulas to test actual flights for appropriateness. The formulas were: [formula: see text] where Y = ground travel time; R = rendezvous time; Z = extrication time; D = distance to scene (km); and X = air travel time. The formulas provide a guide to prospectively determine the legitimacy of air medical transport. They can also be used retrospectively as a guide for quality assurance purposes. During this study of 123 consecutive scene flights, helicopter benefitted all the entrapped patients but only one-third of non-entrapped patients. Of 44 flights from areas with known ground times, helicopter transport benefitted 14 of 16 entrapped, five of 16 non-entrapped, but only three of 17 rendezvous.     

Trauma and nontrauma cardiopulmonary arrest: a national survey

INTRODUCTION: This survey attempts to identify the current standard of care for the air medical transport of the patient in cardiopulmonary arrest. METHOD: An Association of Air Medical Services/National Flight Nurses Association-approved survey by a single mailing with an anonymous response. SETTING: All rotor-craft programs with current memberships in AAMS. RESULTS: Fifty-three of the 178 questionnaires mailed were returned. Program demographics, crew composition and transport volumes were typical of other reported national experiences. The majority of programs (84%) had standing operational protocols for trauma and non-trauma cardiopulmonary arrests. The indications for not initiating or discontinuing CPR, the transport of the patient in cardiopulmonary arrest, triage and financial considerations varied widely between air medical programs. CONCLUSIONS: This study provides some insight on the current air medical management of the patient in cardiopulmonary arrest. National practice guidelines should be developed and tested prospectively in future studies.     

Does crew resource management training work?

INTRODUCTION: Effective crew resource management (CRM) may play a major role in decreasing the number of accidents and increasing overall safety of air medical programs. The purpose of the study was to compare the responses of crew members, in a variety of situations, who received CRM training and those who did not. The numerical results of the responses were used to evaluate the effectiveness of CRM in increasing crew awareness and promoting team concepts. METHOD: During a 12-month period, crew members of randomly selected air medical programs (fixed- and rotor-wing) were surveyed by questionnaire. Participants were asked if they had received CRM, effective communication, and team-building training. The next 15 questions pertained to crew interaction/communication in everyday and emergent situations and were scored on a Likert scale (1 = strongly agree and 5 = strongly disagree). A lower total score indicated a greater understanding of team awareness and effective communication. RESULTS: The mean score of crew members who received the three identified areas of training (initial CRM, team-building, effective communications) (37.96, SD +/- 7.67) was found to be significantly lower than the mean score of those who had received none of the training (44.13, SD +/- 5.0) and P < .05. CONCLUSION: Based on the results, CRM training increases crew awareness and promotes team concepts in both everyday and emergent situations.     

Cabin environment and perception of cabin air quality among commercial aircrew

OBJECTIVE: Our objective was to study the perception of cabin air quality (CAQ) and cabin environment (CE) among commercial cabin crew, and to measure different aspects of CAQ on intercontinental flights. METHODS: A standardized questionnaire was mailed in February-March 1997 to all Stockholm-based aircrew on duty in a Scandinavian flight company (n = 1,857), and office workers from the same company (n = 218). The answers were compared with an external reference group for the questionnaire (MM 040 NA). During this time, smoking was allowed on intercontinental flights, but not on other shorter flights. Smoking was prohibited on all flights after 1 September 1997. The participation rate was 81% (n = 1,513) in the aircrew, and 77% (n = 168) in the office group. Air humidity, temperature, carbon dioxide (CO2) and respirable dust were measured during intercontinental flights, during both smoking and nonsmoking conditions. Statistical analysis was performed by multiple logistic regression analysis, keeping age, gender, smoking, current smoking, occupation, and perceived psychosocial work environment simultanously in the model. RESULTS: Air humidity was very low (mean 5%) during intercontinental flights. In most cases (97%) the CO2 concentration was below 1,000 ppm. The average concentration of respirable particles was 67 microg x m during smoking conditions, and 4 microg x m(-3) during non-smoking conditions. Complaints of draftiness, too high temperature, varying temperature, stuffy air, dry air, static electricity, noise, inadequate illumination, and dust were more common among aircrew as compared with office workers from the same company. Female crew had more complaints on too low temperature, dry air, and dust. Current smokers had less complaints on stuffy air and environmental tobacco smoke (ETS). Younger subjects and those with atopy (childhood eczema, allergy to tree or grass pollen, or furry animals) reported more complaints. Reports on work stress and lack of influence on working conditions were strongly related to perception of a poor cabin environment. Flight deck crew had more complaints about inadequate illumination and dust, but less complaints about other aspects of the cabin environment, as compared with flight attendants. Aircrew who had been on a flight the previous week, where smoking was allowed, had more complaints on dry air and ETS. CONCLUSION: Complaints about work environment seems to be more common among aircrew than office workers, particularly draft, stuffy air, dry air, static electricity, noise, inadequate illumination and dust. We could identify personal factors of importance, and certain conditions that could be improved, to achieve a better perception of the cabin environment. Important factors were work stress, lack of influence on the working conditions, and environmental tobacco smoke on some longer flights. The hygienic measurements in the cabin, performed only on intercontinental smoking flights, showed that air humidity is very low onboard, and tobacco-smoking onboard leads to significant pollution from respirable dust.     

Air medical transport of patients from offshore oil and gas facilities. Historical accident data and initial experience

The offshore petroleum exploration and production industry (OSI) is isolated from traditional means of access to emergent health care and may benefit from the unique attributes of helicopter air medical transport. This study was undertaken to review the incidence of OSI-related incidents, injuries and deaths, and report the initial experience of a civilian hospital-based helicopter air transport program in the evacuation of offshore patients. It was learned that the mean annual incidence of major OSI accidents from 1980 to 1986 was 19.1 (+/- 7.0). Mean annual mortality and reported injury were 14.7 (+/- 7.6) and 36.7 (+/- 25.4) patients respectively. Fires and explosions were the most frequently reported events at 62 per year (+/- 11.5/year). Nine OSI patients were evacuated by helicopter during the study's eight-month pilot period (seven for trauma and two for medical illness). One of the nine patients had been exposed to a potentially hazardous substance, requiring changes in the air medical team's operations, aircraft and equipment. The study shows that the offshore petroleum environment is ideally suited for air medical transport, as injuries are common and medical illnesses are to be expected. However, air medical programs operating offshore must deal with additional regulatory requirements and develop operational procedures to ensure safety during these flights.