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.     

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.     

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.     

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.     

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.     

Statewide air medical transports for Massachusetts

In 1997, the Massachusetts Department of Public Health (MDPH) established a process to centralize air medical transport information. This database is one of the first statewide, population-based sources for civilian rotary-wing air medical transports (U.S. Coast Guard, police, and military missions are not included). The purpose of this database is to facilitate MDPH review of air medical transport service utilization, with input from a multidisciplinary committee. This article discusses the challenges in producing uniform data from multiple service submissions and presents aggregate "baseline" utilization information for 1996. These data served as a starting point for later studies using data linkage. This indexed article is the first to report statewide, population-based data for all types of air medical helicopter transports. The only other indexed "statewide air medical transport" paper focused on scene transports to trauma centers in Pennsylvania. A previous article by the authors in the July-September 2000 Air Medical Journal provided an overview of air medical transports for fatal motor vehicle crashes for 1 region of the state.     

Emergency air medical transport of U.S.-citizen tourists: 1988 to 1990

STUDY OBJECTIVE: To study the epidemiology of U.S. citizens who become ill or injured while on vacation outside the United States and are transported back to the United States by emergency air medical transports. DESIGN: A retrospective self-reported survey covering a study period of three years (1988-1990) of air medical transport services in the United States. SETTING AND TYPE OF PARTICIPANTS: All members of the Association of Air Medical Services (AAMS) who operate either rotorcraft within range of non-U.S. territories (excluding Canada) or who operate fixed-wing aircraft in the United States. INTERVENTIONS: None. RESULTS: There were a total of 796 cases reported by AAMS members during the study period. Males comprised 61% of the cases. Unintentional injury accounted for 44% (n = 351) of the patients transported. Acute myocardial infarctions, angina and post-cardiac arrest cases comprised 15% (n = 141) of the total cases. Infectious diseases other than pneumonia comprised slightly more than 1% (n = 11) of the total cases. There were 12 gunshot wounds and one stab wound, comprising 1.6% (n = 13) of the total cases. Mexico, the Virgin Islands, and the Bahamas were the top three sites of transport origin, accounting for 59% of the cases. Fixed-wing transport accounted for 90% of the reported flights. CONCLUSIONS: This survey reveals a previously undescribed portion of travel-related morbidity and mortality. Injury prevention needs greater emphasis when travel advice is given by physicians and other travel medical services. Air medical transport is an important aspect of the care of acutely injured or ill U.S.-citizen tourists.     

Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation

INTRODUCTION: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. METHODS: Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. RESULTS: A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome (P=.009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. CONCLUSION: Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.     

Use of restraints in air medical transport: a survey

Although the practice of restraining combative patients is commonplace, restraint has been neither uniform nor scrutinized in the air medical transport environment. The objective of this study was to identify and characterize the use of physical and chemical restraining methods in air medical and critical care transport settings. A retrospective study was performed through faxed questionnaires to 92 medical directors who were members of the Air Medical Physician Association (AMPA). Neither program size nor program type correlated with the use of a particular restraint method. Cloth, including gauze, was the most common physical restraint (73%); both benzodiazepines and paralytics were the most common chemical restraints (53%). Injury to crew members was not widespread. This study of air transport services reported a lower incidence of injury to personnel (17%) than is reported in studies from emergency departments (EDs) (60%). This study also indicated that air transport services possess protocols governing actions toward violent patients (65%) more often than has been reported in studies on EDs (50%). Protocols varied in nature and extent. Consensus protocols should be established and implemented with the aid of detailed data acquisition to standardize personnel education in managing violent patients.     

Air medical transport systems as a health-care integrator. Association of Air Medical Services

Air medical transport services are an essential, cost-effective component of health-care delivery in the United States. Air medical transport services provide rapid access to high-quality, sophisticated medical technologies over large geographic areas. They reduce the cost of duplicating resources by obviating the need to provide similar levels of access and service at multiple locals in the region. The sophistication and quality of care maintained during transport provides a level of services not available with traditional ground transport services, particularly in rural areas. Air medical transport services also facilitate linkages between primary, secondary and tertiary-care facilities, allowing integration of programs and services to create regionalized systems of healthcare. While numerous strategies are necessary to reduce health-care costs in the United States without reducing quality and access, air medical transport systems are uniquely positioned to support the efficient integration of regional healthcare services, while maintaining the highest standards of care for patients.     

中美空军飞行学员医学选拔对照实证研究--扁平足

目的：探讨中美两军飞行学员选拔扁平足医学标准的不同,并对我军标准改革提供一种思路。方法调查2012—2015年我军招飞定选体检中扁平足淘汰率与综合评定（简称综评）合格率,对比我军与美军飞行学员选拔扁平足医学标准,并进行实证研究。结果2012—2015年我军招飞定选体检因扁平足淘汰52例,占骨科疾病淘汰人数的26.40%,扁平足患者综评合格人数为87例,占骨科疾病综评合格人数的37.18%。中美两军关于扁平足医学选拔标准主要区别在于美军标准注重功能,无形态方面要求,我军标准仅有形态学要求。按照美军标准,我军因扁平足淘汰的52例中43例合格,9例不合格;我军扁平足患者综评合格的87例中79例合格,8例不合格。结论招飞定选体检中,因扁平足淘汰的人数较多。我军扁平足医学选拔标准与美军标准差别较大,我军实施的综评机制中考虑功能因素,将是一种较为合理的机制。     

Semicentenary anniversary of the department for the training of physicians for Air Forces

In October the 8 in Military Medical Academy n. a. S. M. Kirov was a conference dedicated to the 50th anniversary of the Faculty of doctors for the Air Force. The issues of history of training and improvement of air doctors were considered, were mentioned the names of the principals of the faculty: B. V. Tikchomirov (1960-1964), B. N. Kudryavtsev (1964-1972), I.I. Zhirkov (1972-1975), S.A. Bugrov (1975-1982), V. F. Zhernavkov (1982-1992), V.A . Afonin (1992-1998), I. N. Lizogub (1998-2003), D. K. Podovinnikov (2003-2008), Yu. M. Bobrov (2008-2010). Quoted the data that more than 200 graduates of the faculty became notable figures in military medicine. Progress of the students in study, sport and scientific research was noted.     

Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers

Introduction: To determine if air medical interhospital transport of patients with spinal injuries is done with techniques that minimize ischemic skin damage

Methods: A formal telephone survey instrument was given to all U.S. flight services accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS).

Results: Thirty-seven active services were listed by CAMTS; the author's service was excluded from the survey. One service did only scene responses; one was unreachable by phone; four were unwilling to complete the form, leaving 30 services for evaluation. Twenty-nine services used metal, plywood, or plastic “spine” boards for immobilization during interhospital transport. Eight services padded boards with blankets or cloth for patients immobilized for “extended periods.” Eighteen services routinely reimmobilized all major trauma patients even if cleared by the sending physician, and four others reimmobilized patients not “cleared” by a radiologist. No service moved patients with known spinal injuries to softer, more conforming devices before transport. Only three services followed patients for complications throughout hospitalization. Two services reported cases of skin breakdown thought to be a result of prolonged immobilization.

Conclusion: Air medical services often transport patients several hours after injury. Patients, particularly those unable to move because of their injuries, medication, or paralysis, are at risk for ischemic necroses of their skin. Decubitus ulcers are a major cause of morbidity and mortality, and preventing ulcers requires a very soft, conforming surface. Despite these facts, the highly select services surveyed continue to use hard, slippery boards designed for extrication at trauma scenes to immobilize patients for transport.     

Reduced emergency department stabilization time before cranial computed tomography in patients undergoing air medical transport

INTRODUCTION: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. SETTING: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. METHODS: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05). RESULTS: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground. CONCLUSION: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.     

美国空中急救概况

美军大规模使用直升飞机转运伤员开始于朝鲜战争及后来的越南战争。根据已取得的成功经验,空中急救(air medicine)现已成为美国平时完整创伤急救系统不可分割的重要组成部分。笔者重点介绍美国空中急救的方法与经验,以供国内创伤急救医学有关人员在决策或开展中国的空中急救项目．时参考。     

A survey of U.S. Army aeromedical equipment

Medical equipment is necessary to support patients requiring air transportation, but it may not be compatible with the aviation environment. Aircraft systems may cause errors in the functioning of medical equipment, or that equipment may interfere with the aircraft. Medical equipment has been tested, primarily for fixed wing aircraft, to military standards by the U.S. Air Force. This study reports 1986 and 1987 surveys which document the use of such equipment on U.S. Army medical evacuation aircraft and compares items in current use to the U.S. Air Force's test results. Of the 115 different nonissue items reported in use, 32 have been formally evaluated, and 9 of those were judged unacceptable for use on aircraft. Only two items reported in the survey were tested inflight in helicopters. The remaining 83 items have not been tested. Helicopters have unique requirements, and the U.S. Army has begun a program to evaluate medical equipment for helicopter use.     

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.