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?