The 2003 Air Medical Leadership Congress: findings and recommendations

To address important concerns facing the air medical community, 149 air medical transport leaders, providers, consultants, and experts met September 4-6, 2003, in Salt Lake City, Utah, for a 3-day summit-the Air Medical Leadership Congress: Setting the Health Care Agenda for the Air Medical Community. Using data from a Web-based survey, top air medical transport issues were identified in four core areas: safety, medical care, cost/benefit, and regulatory/compliance. This report reviews the findings of previous congresses and summarizes the discussions, findings, recommendations, and proposed industry actions to address these issues as set forth by the 2003 congress participants.     

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.     

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.     

Improved flight following through continuous quality improvement

Introduction: Flight following is a key component of an air medical transport service's safety program. National standards require conscientious adherence to flight following. EastCare monitored its compliance with internal flight-following requirements for three years. Setting: EastCare is a single-helicopter, hospital-based air medical transport service located in a rural region of the southeastern United States. It has a full-time staff of flight nurses, pilots and communications specialists. Methods: A continuous quality improvement (CQI) process was initiated to delineate specific areas requiring improvement. These areas were discussed at the air medical service's monthly CQI meetings. Results: In 1989, the communications specialists achieved flight following intervals of < or = 15 minutes in 98% of attempts. In 1990 and 1991, the frequency of flight-following intervals of < or = 15 minutes were 98.8% and 99.6%, respectively. The CQI process pointed out educational requirements, technological problems and other areas for improvement. Conclusion: The use of a structured CQI process for this service directly contributed to consistently strong compliance in the frequency of flight following.     

A regional review of air medical transports for fatal motor vehicle crashes

This article presents study results from an assessment of the performance of the air medical (and advanced life support) components of the EMS system in response to fatal motor vehicle crashes. Results are presented for one of Massachusetts' five EMS regions, including the finding that air medical transports are involved in 20% of the fatal crashes for the region and transport 11% of the involved individuals. Although the study focused on air medical utilization, it also identified issues related to the future implementation of motor vehicle automatic crash notification (ACN) and telematics that could relay crash severity data from onboard computers (e.g., event data recorders) to auto manufacturers' help centers or state emergency call centers. This technology will place new demands on state EMS systems. To meet the challenges posed by these technological changes, states will need to assess the type and number of EMS services required to respond to ACN motor vehicle crashes and develop methods to determine what level of service to deploy based on the information relayed from the vehicles. An initial step in this evaluation process is to determine the current use of EMS resources to place planned system changes and demand into context.     

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.     

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.     

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。     

Air ambulance regulations: a model

Prior attempts at establishing minimal federal air ambulance regulations and standards have been unsuccessful. However, reports of poor patient medical care during transport by some air ambulance services is now forcing many states to initiate air ambulance regulations. In 1984, the State of Utah Emergency Medical Services convened a special subcommittee to develop aeromedical regulations for the State of Utah. Using a three-level approach based upon the patient's requirements for basic, advanced, or specialized medical care and the urgency of transport, the subcommittee was able to derive medical categories necessary for the selection and utilization of air ambulance services. Minimum air ambulance regulations were then established for aircraft configuration, flight crew requirements, minimal equipment and medications, and the responsibilities of the medical director or designee for each of the three levels of medical care. We conclude that the application of a levels approach based upon the patient's medical requirements may be useful in assisting other states attempting to establish flexible but specific regulations directed at the safe transport of patients by aeromedical evacuation.     

U.S. Army MEDEVAC in the new millennium: a medical perspective

The U.S. Army Aeromedical Evacuation community (MEDEVAC) possesses a long-standing tradition of excellence in the care and transportation of combat casualties. Recent developments in civilian air medical transport and quantitative review of MEDEVAC operations have identified potential areas for improvement, concentrating on enhanced flight medic standards, training, sustainment and medical oversight of the air ambulance system. These proposed changes are discussed in detail, from the perspective of current emergency medicine and aviation medicine standards of practice. If instituted, these changes would facilitate the emergence of a true air medical transport capability comparable with the civilian community standard.     

Medical considerations in the use of helicopters in mountain rescue

The outcome of patient care can be dramatically improved by bringing rapid rescue and medical care to the mountain rescue scene and by rapid transport to a medical facility. The use of a helicopter for these purposes is common. It is necessary when it has clear advantages for victims in comparison with ground rescue and transport. Helicopters should work within the existing emergency medical system and must be staffed by appropriate mountain rescue and medically trained personnel. Activation time should be as short as possible. Activation of a helicopter for a mountain rescue should primarily include indication and assessment of flight and safety conditions. No other mediators or delaying factors should be permitted. The main safety criteria are appropriate mountain rescue and flight training, competence of air and ground crews, radio communication between the air and ground crews, and mission briefing before the rescue. Criteria for a helicopter used for mountain rescue are proper medical and rescue equipment, load capacity, adequate space, and others. There are two main groups of indications for use of a helicopter for mountain rescue: the patient's condition and the circumstances at the site of the accident. All persons responsible for the activation of the helicopter rescue operation should be aware of specific problems in the mountains or wilderness.     

Integrating emergency medicine residents into a well-established helicopter program

INTRODUCTION: The institution of an emergency medicine residency in a university-affiliated Level 1 trauma center in July 1993 provided a challenge to develop a curriculum and on-line learning experience for emergency medicine residents in a well-established helicopter program. The purpose of this study was to survey flight crew members, emergency medicine at tending physicians, and emergency medicine residents on the anticipated roles and educational experience of integrating the emergency medicine residents from a new emergency medicine residency into the flight crew of a well-established helicopter program. METHODS: A survey consisting of multiple choice, Likert scale, and open-ended questions was distributed to flight crew members (RN, RT, pilots, communication specialists, EM attendings, and EM residents [n=72]). RESULTS: 92% of surveys were returned. These surveys identified specific issues of concern and those areas believed to be of academic importance for the emergency medicine residents. CONCLUSIONS: The results of this study allowed for the creation and implementation of a progressive flight experience for EM residents that incorporates increasing responsibility on the flight crew as experience is gained.     

The impact of multiple patient transport on patient care in helicopter emergency medical services

INTRODUCTION: Many helicopter emergency medical services can transport either one (singles) or two (doubles) patients. The purpose of this study was to investigate whether the additional patient in the doubles flight had an adverse impact on patient care because of the deceased provider-to-patient ratio. SETTING: Patients were flown by a Level 1 trauma center-based helicopter emergency medical service staffed by a nurse and paramedic. METHOD. A retrospective record and trauma registry review comparing 124 randomly selected scene trauma singles frequency-matched to 100 doubles (1/89 through 6/92) was performed. Data collected included patient demographics, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, mechanism of injury, scene time, and ground ALS and helicopter emergency medical services procedures performed. RESULTS: Doubles accounted for 6.5% of all on-scene helicopter emergency medical service trauma patient transports. Paired comparison of Glasgow Coma Scale, Revised Trauma Score, and Injury Severity Score revealed that only one of the doubles patients had a field Glasgow Coma Scale as low, or a Injury Severity Score as high as the average singles. Revised trauma scores were equivalent. Although more procedures were performed during doubles missions, no procedures were performed in most singles missions (58%) and a substantial minority of doubles missions (41%). No differences were found between the groups in change in Glasgow Coma Scale during flight. CONCLUSION: Only of the two patients during doubles missions was as severely injured as the average patient in a singles transport. The decreased ratio of helicopter emergency medical service crew to patients in doubles missions does not jeopardize patient care because few procedures were performed during either singles or doubles missions.     

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.     

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.     

A comparison of emergency medical helicopter accident rates in the United States and the Federal Republic of Germany

The purpose of this study was to compare accident rates of helicopter emergency medical services (USA-HEMS) to domestic air taxi service (USA-Taxi) and helicopter emergency medical services in the Federal Republic of Germany (FRG-HEMS). Contingency tables compared the total hours flown to the number of fatal and non-fatal accidents for USA-HEMS (1982-7) vs. USA-Taxi (1980-5) and USA-HEMS (1982-7) vs. FRG-HEMS (1982-7). The overall accident rate for USA-HEMS was 11.7/100,000 h, with the fatal accident rate being 4.7/100,000 h. This was significantly different from the USA-Taxi overall accident rate of 6.7/100,000 h and the fatal accident rate of 1.6/100,000 h (chi 2 = 20.441, p = 0.0001). The USA-HEMS overall and fatal accident rates were not significantly different than the FRG-HEMS overall (10.9/100,000 h) and fatal (4.1/100,000 h) accident rate (chi 2 = 0.061, p = 0.97). These data suggest that emergency air transport is inherently more risky than routine air taxi 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.     

Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients

STUDY OBJECTIVE: To determine the rate of disagreement in assessment of significant illness or injury between air medical transport team assessment and emergency department (ED) diagnosis in patients transferred from the scene of an incident to the ED. METHODS: Retrospective analysis was performed on 84 patients transported by medical flight teams from an accident scene to an ED. RESULTS: Results show transport team assessment concurred with ED diagnosis 96.7% of the time; most of the differences in assessment were overassessments by the transport team. Assessment differences occurred most often for abdominal injuries and least often for head injuries. Underassessment occurred most often for spinal cord injuries. CONCLUSIONS: Despite the numerous difficulties involved in patient assessment, data show that the transport teams accurately evaluated patients in most instances. Disagreements in assessment of injury/illness most often were overassessments.     

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.