Helicopter Emergency Medical Services… Not Just For Trauma
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Transcript Helicopter Emergency Medical Services… Not Just For Trauma
Helicopter Emergency Medical
Services…
Not Just For Trauma Anymore
Deb Funk, M.D., FACEP, NREMT-P
Medical Director, Life Net of NY
Assistant Professor, Department of Emergency Medicine,
Albany Medical College
Emergency Medical
Services…not just a fast ride with
lights and sirens anymore
Emergency Medical
Technicians…not just ambulance
drivers anymore
Today’s Reality…
The practice of medicine in many environments
has changed
Financial issues
Staffing shortages
The organization of health care has changed
Consolidation of services
Creation of health care systems
Fiscal responsibility
Mission profiles of hospitals, ground based EMS
and air medical services have changed
Team approach to provide health care to an individual
in crisis
History of Air Medical Transport
in the United States
1st reported air transport of a patient in 1915
French pilot evacuated a Serb in an unmodified fighter
plane
Through progressive conflicts, airplane evacuation
of injured/ill more prominent
First medical use of helicopter in 1944 in Burma
First large scale medical evacuation in Korea
(Sikorsky with outboard stretchers)
UH-1H “Huey” central to medical care in Vietnam
This approach reduced mortality and came to the
attention of the American public
Civilian Adaptation
Early 1970’s federally funded pilot projects to
study feasibility
Tenuous economic viability
Need to dedicate to medical configuration
Need for integration into ground EMS systems
Civilian Law Enforcement/Fire Agencies
developed aviation components
Occasionally provided medical transport
Some pursued dedicated air medical programs
Maryland State Police
LA County Fire Dept
Development in Civilian World
Hospital Based
Most common
Aircraft is leased from vendor or owned by hospital
First in Denver 1972
Second Generation in early 1980’s
Increasing federal interest due to cost
Role expanded from trauma to neonatal, OB, cardiac
Third Generation in mid-1980’s
Focus on safety, and cost effectiveness
Current Trends in Aeromedicine
30+ years of helicopter transport
USA - Over 200 hospital based programs
100,000+ patients transported annually
“Brings the hospital” to the patient
Review of Ground EMS
Development
Ground based EMS developed also as a result of
wartime experiences
Multiple models of system
Private contractor
FD based
Private, for profit service
Municipal third service
Multiple levels of provider-regionally dependent
First Responders/Emergency Medical Technicians
(BLS)
Intermediate/Paramedic (ALS)
Specialty Care Paramedic
Integration of Ground and Air
EMS
Team approach
Education
Protocols
Quality Assurance
Indications for Air Transport
Time
Decrease time to definitive care
Decrease out of hospital time
Terrain
Overcome environmental obstacles
Overfly traffic gridlock
Talent
Delivery of highly skilled care to patients prior
to/during transport
Air Medical Triage
>1,000,000 patients transported by
helicopter since 1972 by nearly 200
programs
Roughly 30/70 split scene/interfacility
Triage of patients to receive air transport
Intend for majority of seriously ill/injured
patients get appropriate transport
Assumes a certain over-triage rate
Practical Considerations:
Method of Transport
Optimal time dictated by patient’s
illness/injury
Distance, geography and traffic
Availability of definitive care at local
hospitals
Carrier and personnel availability
Weather conditions
Cost
Considerations: Trauma
Disease of time: minutes make a difference
ACS/COT advocates that any seriously
injured patient be primarily treated in a
trauma center
Air medical transport based upon local factors
Interfacility transport of seriously injured
patient
Use of helicopter based on time/terrain/talent
Considerations: Non-Trauma
Variety of medical/surgical conditions
Time/Terrain/Talent
May benefit from specialty team
(OB/NICU/PICU)
Interfacility most common
Scene may be appropriate
Contraindications to Air
Transport
Terminally ill with no correctable medical
problems
Cardiac arrest without SROC
Patients likely to die enroute, if in a facility
capable of resuscitation
Patients in active labor if delivery expected
during transport
Patients prone to psychotic/violent behavior
(without appropriate restraint)
Utilization Review
Prospective Screening
Difficult based on limited info and time constraints
Retrospective Review
Chart review of outcome, procedures
performed,severity of illness, other subjective
parameters
Follow Up
Feedback to caller
Revision of criteria as appropriate
Case 1
Grandpa and Little Johnnie were involved in a
high speed head on MVC 5 miles from Nowhere.
Grandpa is on coumadin and has a tender,
distended abdomen. His HR is 120
Johnnie is unconscious with an obvious skull
fracture. His jaw is clenched.
20 min drive to community hospital
20 min flight to trauma center (60min drive)
Case 1 Discussion
PEDIATRIC MAJOR TRAUMA
Johnnie needs an airway
and a pediatric
neurosurgeon
Determine quickest way to
airway
HEMS vs community
hospital
Never wait on scene if
packaged
Definitive care at peds
trauma center
Consideration for
automatic standby
1.
Pulse greater than normal range for
patient’s age
2.
Systolic blood pressure below normal
range
3.
Respiratory status inadequate (central
cyanosis, respiratory rate low for the
child’s age, capillary refill time greater
than two seconds)
4.
Glasgow coma scale less than 14
5.
penetrating injuries of the trunk, head,
neck, chest, abdomen or groin.
6.
two or more proximal long bone
fractures
7.
flail chest
8.
combined system trauma that involves
two or more body systems, injuries or
major blunt trauma to the chest or
abdomen
9.
spinal cord injury or limb paralysis
10. amputation (except digits)
Case 1 Discussion
Grandpa needs blood
products and a surgeon
Determine most
appropriate facility
Know local capabilities
Stabilization vs
primary transport to
trauma center
Consider med control
2 patients=2 aircraft
ADULT MAJOR TRAUMA
1.
2.
GCS less than or equal to 13
Respiratory Rate less than 10 or more
than 29 breaths per minute
3.
Pulse rate is less than 50 or more than
120 beats per minute
4.
Systolic blood pressure is less than
90mmHg
5.
Penetrating injuries to head, neck, torso
or proximal extremities
6.
Two or more suspected proximal long
bone fractures
7.
Suspected flail chest
8.
Suspected spinal cord injury or limb
paralysis
9.
Amputation (except digits)
10. Suspected pelvic fracture
11. Open or depressed skull fracture
Case 2
Jake narrowly escapes from his burning
apartment but suffers 60% second degree
burns.
20 min drive to community hospital
20 min flight to trauma center
60 min flight to burn center
Case 2 Discussion
Jake may need airway
protection
Definitive care at burn
center
Consideration for non
burn injuries
CRITICAL BURNS
1.
Greater than 20% Body Surface Area
(BSA) second or third degree burns
2.
Evidence of airway/facial burns
3.
Circumferential extremity burns
**Note that for patients with burns and
coexisting trauma, the traumatic
injury should be considered the first
priority and the patient should be
triaged to the closest appropriate
trauma center for initial stabilization.
Case 3
Mrs. Brown had chest pain and ST elevation in
inferior leads
20 min drive to community hospital
30 min flight to STEMI center (70min drive)
Case 3 Discussion
Time to reperfusion
2004 AHA/ACC
guidelines
Consideration of
destination
Local protocol
Med control
CRITICAL MEDICAL CONDITIONS
1.
a.
b.
Suspected Acute Myocardial
Infarction
Chest pain, Shortness of breath or
other symptoms typical of a cardiac
event
EKG findings of
i.
ST elevation
1mm or more in 2 or more contiguous
leads
OR
ii.
LBBB (QRS
duration >.12msec and Q wave in V1
or V2)
Case 4
Mr. George has right arm and leg weakness
with slurred speech. Last normal 30min
ago.
20 min drive to community hospital
30 min flight to Stroke Center (70min drive)
Case 4 Discussion
Stroke is extremely time
dependent
3hr window for IV TPA
6hr window for IA TPA
Endovascular intervention
Most appropriate
destination
Patient factors
Timing
Med control
CRITICAL MEDICAL CONDITIONS
1.
Suspected acute stroke
a.
Positive Cincinnati Pre-Hospital
Stroke Scale
Total prehospital time (time from when the
patient’s symptoms and/or signs first
began to when the patient is expected
to arrive at the Stroke Center) is less
than two (2) hours.
NYS HEMS Utilization Criteria
Standard criteria described in Policy 05-05
Who calls
When to call
When to cancel
Specific local differences acknowledged
Education tool in development
“Specific Local Differences”
HEMS must be integrated into current EMS
and hospital system
Requires cooperative preplanning
Demands ongoing review
Summary
The practice of medicine evolves
Consolidation of specialty services
continues
Considerations for air medical transport
may be changing
Cooperative plans are imperative for a
successful system
Questions?