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.     

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.     

Pre-competition anxiety and performance in female high school swimmers: a test of optimal function theory

This investigation attempted to test Hanin's theory of optimal function in 15 female high school swimmers. Each swimmer completed the State Anxiety Inventory (STAI) and the Body Awareness Scale (BAS) under the following conditions: I) baseline; II) retrospective recall of "best", "usual", and "worst" performances; III) 24 h prior to an easy and difficult dual meet with instructions to respond as to "how you think you will feel 1 h before the meet"; and IV) 1 h before the meets utilizing the standard ("right now") instructional set. Success was determined in each meet by two methods: 1) objective ratings based on comparisons with the average of times from previous meets; and 2) subjective ratings of performance made by the coach. In the difficult meet significant (P less than 0.01) increases in precompetition anxiety and body awareness occurred, and the correlations between predicted and actual pre-competition were .95 (P less than 0.001) for both anxiety and body awareness. In the difficult meet swimmers subjectively classified as successful were more accurate (P less than 0.05) in predicting precompetition anxiety, and possessed pre-competition anxiety values that were closer to their recall of optimal pre-competition anxiety compared to the unsuccessful swimmers. No comparisons based on the objective classifications were significant, nor were any of the comparisons in the easy meet. The present findings support Hanin's optimal function theory.     

Long-distance air evacuation of blast-injured sailors from the U.S.S. Cole

BACKGROUND: The U.S. military uses a Critical Care Air Transport Team (CCATT) to air evacuate critically ill patients to facilities that can provide definitive medical care. CCATT is comprised of highly trained personnel and each team uses specialized equipment to allow for in-flight intensive medical care of patients. CCATT has the capability of providing care over long duration and distance. This report describes our recent experience of long-distance fixed-wing medical air evacuation of multiple critically ill sailors with blast injuries from the U.S.S. Cole. CONCLUSION: CCATTs can safely transport multiple critical patients with blast injuries over long distance and duration by fixed-wing aircraft. Blast injuries can have multi-system effects and patients with subclinical pulmonary injury may be asymptomatic when hypoxemic in a hypobaric environment.     

Raised Anxiety Levels Among Outpatients Preparing to Undergo a Medical Imaging Procedure: Prevalence and Correlates

PurposeTo examine the percentage of patients with raised state anxiety levels before undergoing a medical imaging procedure; their attribution of procedural-related anxiety or worry; and sociodemographic, health, and procedural characteristics associated with raised state anxiety levels.Materials and MethodsThis prospective cross-sectional study was undertaken in the outpatient medical imaging department at a major public hospital in Australia, with institutional board approval. Adult outpatients undergoing a medical imaging procedure (CT, x-ray, MRI, ultrasound, angiography, or fluoroscopy) completed a preprocedural survey. Anxiety was measured by the short-form state scale of the six-item State-Trait Anxiety Inventory (STAI: Y-6). The number and percentage of participants who reported raised anxiety levels (defined as a STAI: Y-6 score ≥ 33.16) and their attribution of procedural-related anxiety or worry were calculated. Characteristics associated with raised anxiety were examined using multiple logistic regression analysis.ResultsOf the 548 (86%) patients who consented to participate, 488 (77%) completed all STAI: Y-6 items. Half of the participants (n = 240; 49%) experienced raised anxiety, and of these, 48% (n = 114) reported feeling most anxious or worried about the possible results. Female gender, imaging modality, medical condition, first time having the procedure, and lower patient-perceived health status were statistically significantly associated with raised anxiety levels.ConclusionRaised anxiety is common before medical imaging procedures and is mostly attributed to the possible results. Providing increased psychological preparation, particularly to patients with circulatory conditions or neoplasms or those that do not know their medical condition, may help reduce preprocedural anxiety among these subgroups.     

Cognitive coping and anxiety symptoms among people who seek help for fear of flying

INTRODUCTION: Fear of flying among potential passengers is rather common. In order to treat fear of flying most efficiently, it is important to find out which aspects are related to flight anxiety. The objective of the present study was to examine the extent to which various cognitive coping strategies in response to a flight were used by airline passengers and their relationship with anxiety symptoms. METHOD: A total of 261 persons who were all seeking treatment for fear of flying filled in the Cognitive Emotion Regulation Questionnaire, the anxiety subscales of the Symptom Check List (SCL-90), the Flight Anxiety Situations questionnaire, and the Flight Anxiety Modality questionnaire. RESULTS: Respondents reported using refocus on planning, rumination, putting into perspective to the highest extent and catastrophizing and other-blame to the lowest extent. Furthermore, respondents who reported using self-blame, acceptance, rumination, and/or catastrophizing to a higher extent also reported significantly higher levels of anxiety. DISCUSSION: As the present study suggests that several cognitive coping strategies are related to anxiety, intervention programs should pay attention to these aspects. The present study gives important clues about which cognitive coping strategies should be challenged in treatment of flight anxiety.     

Legal implications of information to the patient in nuclear medicine

Every patient has the right to be informed about a medical procedure. The nuclear medicine physician has the duty to inform the patients and, if necessary, to obtain a reasonable written consent before some radioisotopic examinations. The following must be considered in every informed consent of a nuclear medicine procedure: the need for the patient information ("why"), the type of information given ("how"), the person who performs it ("who"), the moment in the time ("when") and the place ("where") where the consent is performed. It must always be kept in mind that, although the informed consent has a protection function from the medicolegal point of view, this function may be lost if the consent is not performed correctly. In this paper the importance and the medicolegal implications of the patient information in Nuclear Medicine are evaluated and discussed.     

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.     

The use of chemical restraint in helicopter transport

Introduction: Helicopter transport of the combative patient is a major safety hazard facing air medical teams. Although physical restraints alone are helpful, the addition of chemical restraint (CR) often is necessary to control these patients while in flight.

Methods: A survey was conducted to determine the current practices of using nonparalyzing CR in air medical transport programs nationwide. The survey consisted of 24 questions on the use of CR during transport. Each U.S. program belonging to the Association of Air Medical Services was contacted by telephone, and a flight nurse or paramedic provided answers based on personal experience and statistics compiled by his or her individual program.

Results: Of the 100 programs responding, benzodiazepines were used most commonly to control agitation with 51% using midazolam. Patients with a head injury required CR more frequently than any other condition (73%). Crews flying larger aircraft reported less need for CR. A physician order was required by only 30% of the programs, but delays infrequently endangered the patient (2%). Only 7% of the responding programs had a patient whose condition deteriorated because of CR.

Conclusion: CR is necessary in air medical transport. Most programs use short-acting benzodiazepines. Crews in smaller aircraft use CR more frequently, and head injury is the most common condition requiring such restraint.     

A national survey of the air medical transport of high-risk obstetric patients

INTRODUCTION: Air medical transport of high-risk obstetric (HROB) patients can be accomplished and advantageous for neonate survival and maternal morbidity. A survey of U.S. helicopter air medical programs was conducted to determine the frequency and current practices of HROB transport. METHODS: Each program was contacted by telephone, and air medical personnel were asked to answer 12 questions based on personal experience and statistics compiled by their programs. RESULTS: Of the 203 programs surveyed, 133 (66%) provided responses. The mean number of HROB transports was 45.6 per year (4.6% of the mean 995 total transports). Although 83% of the responding programs used the standard flight crew during the HROB transport, only 52% required crew members to maintain neonatal resuscitation certification. Only 56% of the aircraft allow pelvic access in the normal patient configuration. While only 22% of programs have specific HROB launch (dispatch) protocols, 50% reported having obstetricians involved in dispatching flights, and 84% carry tocolytic agents in their drug kit. The greatest concerns included in-flight delivery (60%), inadequate fetal monitoring (6%), and inexperience (5%). CONCLUSION: While HROBs account for 5% of air medical flights, many programs appear to be poorly prepared for these patients.     

Exacerbation of pneumomediastinum after air travel in a patient with dermatomyositis

BACKGROUND: Although the presence of pneumothorax is generally considered an absolute contraindication to air travel, reports on pneumomediastinum after air travel are extremely rare. Moreover, to the best of our knowledge, exacerbation of existing pneumomediastinum after commercial air travel has never been reported. CASE REPORT: We report on a case of a patient (the first case that we are aware of) who suffered exacerbation of pneumomediastinum after commercial air travel. This patient, with confirmed pneumomediastinum before air travel, flew to our city for medical care without being warned about exacerbation by the local hospital or airlines. Obvious exacerbation of pneumomediastinum and subcutaneous emphysema was noticed after the travel. Subsequently, a diagnosis of amyopathic dermatomyositis with interstitial lung disease and pneumomediastinum was made. The patient died despite treatment with corticosteroid, cyclophosphamide and intravenous immunoglobulin. This report discusses this rare condition and offers suggestions regarding air travel for patients with presence of pneumomediastinum at the time of flight.     

Transcranial oximetry as a new monitoring method for HEMS (Helicopter EMS).

INTRODUCTION: Transcranial oximetry (TCO) is a new method to measure continuous changes in brain blood oxygen saturation (rSO2) by using near-infrared spectroscopy (NIRS). To our knowledge, no studies about TCO in air medical transport have been published. METHODS: Twenty healthy volunteers (HEMS medical crew) were investigated during flight missions without patients. We measured oxygen saturation (SpO2), cardiac rate, and rSO2 with an INVOS 4100 Cerebral Oximeter at sea level and at each 1000 feet until we reached a flight level of 5000 feet. RESULTS: The oximeter did not produce any interference with medical or aeronautical equipment. Subjects' SpO2 showed a slight decrease with altitude (P < 0.010), but rSO2 remained constant (P = 0.28), with little delay in the physiological correction of SpO2 and rSO2 values. CONCLUSION: TCO may play an important role in the development of new monitoring methods for critical patients in air medical transport. Further studies with large sample sizes and patients are necessary to generalize findings.     

Naproxen sodium and paracetamol/dextropropoxyphene in sports injuries - a multicentre comparative study.

This paper follows up a previous paper reported in this journal. This study was a single-blind parallel comparison of naproxen sodium ("Synflex") and a paracetamol/dextropropoxyphene combination ("Distalgesic"). It was carried out in 184 patients suffering from soft-tissue disorders recruited from four centres. More patients were considered cured and the pain score was significantly lower after seven days' treatment in the naproxen sodium ("NS") group. For those patients who received 14 days' treatment the total symptom score was significantly lower in the naproxen sodium group at the end of treatment. Two patients in the NS treatment group withdrew from the study due to lack of efficacy. Fewer side-effects were reported in the NS group. Of the eight patients stopping treatment due to side-effects, two were in the naproxen sodium group and six in the paracetamol/dextropropoxyphene ("control") group. The results suggest that a better clinical response to treatment and fewer side-effects may be obtained with naproxen sodium than with paracetamol/dextropropoxyphene in the treatment of soft-tissue injuries.     

International Space Station medical standards and certification for space flight participants

INTRODUCTION: The medical community of the International Space Station (ISS) has developed joint medical standards and evaluation requirements for Space Flight Participants ("space tourists") which are used by the ISS medical certification board to determine medical eligibility of individuals other than professional astronauts (cosmonauts) for short-duration space flight to the ISS. These individuals are generally fare-paying passengers without operational responsibilities. MATERIAL AND CONTEXT: By means of this publication, the medical standards and evaluation requirements for the ISS Space Flight Participants are offered to the aerospace medicine and commercial spaceflight communities for reference purposes. It is emphasized that the criteria applied to the ISS spaceflight participant candidates are substantially less stringent than those for professional astronauts and/or crewmembers of visiting and long-duration missions to the ISS. CONCLUSIONS: These medical standards are released by the government space agencies to facilitate the development of robust medical screening and medical risk assessment approaches in the context of the evolving commercial human spaceflight industry.     

The Air Medical Leadership Congress: setting the health care agenda for the air medical community

BACKGROUND: Emergency air medical transport provides the means for critically ill or injured patients to rapidly access sophisticated medical flight teams and medical centers. However, issues such as surging emergency medical services helicopter accidents, expected pilot and nurse shortages, falling reimbursements, and new compliance regulations are now threatening these important but expensive transport services. Unless an industry strategy can be developed to address these and other threats, many medical flight programs may be forced to curtail the availability of these lifesaving services. PURPOSE: On September 4-6, 2003, air medical leaders, experts, program managers, providers, and users of emergency air medical services gathered in Salt Lake City, Utah, to discuss and formulate recommendations to address the top issues that threaten the future of air medical transport services. This congress was open to anyone engaged in the field of air medical transport. This historic meeting resulted in a plan to enhance transport safety, foster appropriate utilization, improve in-flight medical care, maximize cost and reimbursement effectiveness, and develop strategies to reduce the adverse effects of new regulatory and compliance mandates. OBJECTIVES: This article describes the significance of the Air Medical Leadership Congress and the 10-Point Plan method used to develop it.     

Cabin configuration and prolonged oral endotracheal intubation in the AS365N2 Dauphin EMS helicopter

INTRODUCTION: Most patients transported by air who require endotracheal intubation undergo endotracheal intubation before transport. However, in-flight endotracheal intubation may be indicated in the setting of certain scene conditions, in-flight patient deterioration, or endotracheal tube dislodgement. A previous report of high endotracheal intubation efficacy in the BK-117 in-flight recommended that flight programs review endotracheal intubation capabilities in their own aircraft. This study was conducted to determine whether in-aircraft endotracheal intubation times in the AS365N2 Dauphin were comparable to those previously reported for the BK-117. SETTING: AS365N2 and BK-117 helicopters stationary on a helipad. METHODS: Eight flight team members per formed three mannequin endotracheal intubations in each aircraft. Three time intervals were assessed: Setup, time required for equipping and positioning for endotracheal intubation; placement, time from laryngoscopy to endotracheal intubation; and total (Setup + Placement). Mean times for the BK-117 and AS365N2 were compared using the t test (a=0.05). RESULTS: All endotracheal intubation attempts were successful, but setup (p=0.0001), placement (p=0.0271), and total (p=0.0011) times were longer in the Dauphin. Crew members unanimously expressed endotracheal intubation difficulty caused by positioning problems in the Dauphin. CONCLUSION: In-aircraft intubation is significantly more time-consuming in the Dauphin than in the BK-117. This prolongation of intubation appears to be due to problems with positioning of the air medical crew and patient.     

A review of drug use during air medical transport to optimize an air ambulance formulary

INTRODUCTION: The advent of air medical transport has pushed the delivery of critical care medicine into the prehospital arena. As a result, a wide variety of pharmacologic agents must be available in the air medical setting. PURPOSE: The purpose of this study was to conduct a retrospective review of drugs used during air medical transport to allow a streamlining of the air ambulance formulary. METHODS: All flights completed since the inception of the study's helicopter air ambulance program in 1985 through September 1991 were analyzed to determine which medications were used in flight. Drugs were counted if they were administered while in flight for either a scene or interhospital transport. RESULTS: Review of 2,694 flights showed that 45 individual drugs had been routinely carried during the study period. Many of these agents were administered fewer than five times during the six years, and 10 drugs were not used at all. CONCLUSION: As a result of this investigation, the formulary for our air medical transport service was modified. The authors recommend similar critical audits of drugs carried in flight be performed by other air ambulance services.     

Long-distance transport of ventilated patients: advantages and limitations of air medical repatriation on commercial airlines

INTRODUCTION: To illustrate the advantages and limitations of transporting ventilated intensive care unit patients over intercontinental distances on commercial airlines, this case series reports 8 ventilated patients repatriated by an air medical transport company. PATIENTS: Eight ventilated patients, 3 suffering from internal and 5 from neurologic diseases. Distances ranged from 1700 to 10280 nautical miles with transport times from 04:10 hours to 21:55 hours. For 3 patients, a dedicated patient transport compartment (PTC) in the aircraft cabin was used. All patients were ventilator-dependent for a minimum of 11 days before transport (48 days median, 113 days maximum). RESULTS: One patient went into cardiac arrest during the flight and died. None of the other patients experienced any emergency or invasive procedures, other than peripheral venous access necessary during the flight. In all patients, ventilation was adjusted with respect to the blood gas analysis at least once during the transport. No technical failures or drop-outs occurred during the flights. None of the flights had to be diverted for technical or medical reasons. CONCLUSION: Long distance international transport of ventilated intensive care unit patients is an extremely cost intensive and logistically challenging task. In a certain subgroup of relatively stable ventilated patients, transport on commercial airlines offers advantages in terms of cost effectiveness and reduced transport time and acceleration/deceleration trauma as a result of multiple fuel stops.