Acute aortic dissection during scuba diving.

A 60-year-old man with hypertension and dyslipidemia complained of chest pain upon ascending from a maximum depth of 27 meters while diving. After reaching the shore, his chest pain persisted, and he called an ambulance. When a physician checked him on the doctor's helicopter, his electrocardiogram (ECG) was normal, and there were no bubbles in his inferior vena cava or heart on a portable ultrasound examination. The physician still suspected that he had acute coronary syndrome instead of decompression illness; therefore, he was transported to our hospital. After arrival at the hospital, standard cardiac echography showed a flap in the ascending aorta. Immediate enhanced computed tomography revealed Stanford type A aortic dissection. The patient obtained a survival outcome after emergency surgery. To our knowledge, this is the first reported case of aortic dissection potentially associated with scuba diving. It highlights the importance of considering aortic dissection in patients with sudden-onset chest pain during physical activity. In addition, this serves as a reminder that symptoms during scuba diving are not always related to decompression. This report also suggests the usefulness of on-site ultrasound for the differential diagnosis of decompression sickness from endogenous diseases that induce chest pain. Further clinical studies of this management approach are warranted.

Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity.

BACKGROUND: That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF. METHODS: From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups. RESULTS: During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group. CONCLUSIONS: The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Usefulness of Key Word Methods to Execute Early Requests for a Physician-Staffed Helicopter Emergency Medical Service Dispatch to Facilitate Early Medical Intervention by Physicians.

OBJECTIVE: A physician-staffed helicopter emergency medical service is called a doctor helicopter (DH) in Japan. We retrospectively investigated this service using a data bank provided by the Japan DH registry system. METHODS: The following details of the dispatch activity were collected: patient age and sex, vital signs (Japan Coma Scale [JCS], systolic blood pressure, heart rate, and respiratory rate) at the scene measured by emergency medical technicians (EMTs), dispatch of the DH before the EMTs made contact with patients (key words group) or after (control group), and the survival outcome at 1 month. RESULTS: During the investigation period, 28,357 patient records were analyzed (key words group, n = 13,861; control group, n = 14,496). The age, JCS, and respiratory rate were significantly smaller in the key words group than in the control group. The rates of male sex and survival in the key words group were significantly greater than those in the control group. In the multivariate analysis, dispatch of the DH after EMTs made contact with the patients (odds ratio [OR] = 0.72; 95% confidence interval [CI], 0.55-0.92), female sex (OR = 0.86; 95% CI, 0.75-0.98), older age (OR = 0.97; 95% CI, 0.96-0.97), elevated respiratory rate (OR = 0.97; 95% CI, 0.97-0.98), and high JCS (OR = 0.99; 95% CI, 0.99-0.99) were associated with a decreased 1-month survival (P > .0001). CONCLUSION: This is the first report to describe the key words method as a potential factor influencing optimal outcomes/potential survival rates in patients evacuated by the DH using the JDRS. Our study results suggest that the firefighting central command room should consider adopting the key words method when the helicopter emergency medical service is used.

A Comparison of Tube Thoracostomy for Chest Trauma Between Prehospital and Inhospital Settings.

OBJECTIVE: We compared the outcomes of patients with tube thoracostomy for chest trauma between the prehospital and inhospital settings. METHODS: The subjects were then divided into 2 groups: the prehospital group, which included subjects who underwent tube thoracostomy in the prehospital setting, and the inhospital group, which included subjects who underwent tube thoracostomy in the inhospital setting. The variables were compared between the 2 groups. RESULTS: There were no significant differences between the 2 groups with regard to gender, age, history, mechanism of injury, infusion of antibiotics, white blood cell count, duration of insertion of a chest drain, mechanical ventilation, complication of drain infection, duration of admission, or final outcome. However, the Injury Severity Score, maximum C-reactive protein level, and maximum temperature during hospitalization in the prehospital group (n = 15) were significantly greater than those in the inhospital group (n = 119). CONCLUSION: The present study suggested that thoracostomy performed by physicians in the prehospital setting was safe and did not have an increased risk of infection. In addition, thoracostomy for chest injury in the prehospital setting suggested an improvement in the likelihood of a survival outcome.

Transportation of Medical Staff by Helicopter to Manage a Concealed Delivery at Home.

An unmarried pregnant woman felt lower abdominal pain. She rested in bed in her room on the second floor in her home. The next day she performed a delivery by herself. After the neonate cried, her parents noticed the birth and called an ambulance. After receiving the first call, the fire department decided to request the dispatch of a physician-staffed helicopter emergency medical service in Eastern Shizuoka, in addition to dispatching an ambulance. After receiving the request, the helicopter emergency medical service transported 1 neonatal intensive care unit physician along with the original medical staff members of the fire department. Then, the 3 medical staff members were transported to the home by another ambulance. When emergency medical technicians climbed up a steep narrow ladder to enter the room, both the mother and female neonate were connected by the umbilical cord. Their vital signs were stable. At 30 minutes after delivery, the medical staff reached the mother and neonate and cut the umbilical cord. The mother and neonate were evacuated separately from the room but transported in the same ambulance. The ambulance transported them with the medical staff members to our hospital directly. Their postadmission courses were uneventful, and they were discharged. This is the first case report to send medical staff members to the patient's home by helicopter and ambulance to provide medical intervention for the neonate and her mother. Further prospective studies are needed in the future to determine whether this action could lead to favorable outcomes in both neonates and maternal bodies.

Patients With Atrioventricular Block Transported by a Physician-Staffed Helicopter in Japan From 2015 to 2020.

OBJECTIVE: We retrospectively investigated the current status of patients with atrioventricular block (AVB) who had been transported by the physician-staffed helicopter emergency medical service and their final outcome using data from the Japan Doctor Helicopter Registry (JDHR) system. METHODS: The following details of the dispatch activity were collected from the database of the JDHR: age and sex, vital signs when emergency medical technicians encountered the patient at the scene and on arrival at the receiving hospitals, contents of the medical intervention, new cardiac arrest during transportation, the main etiology of AVB, and the number of deaths in 1 month. The changes in vital signs between the scene and upon arrival at the hospital were compared. RESULTS: A total of 99 patients had complete AVB. The average age of the patients was 75 years, and there was a male predominance. All subjects were evacuated from the scene. Among the 62 subjects who received the drugs, 18 received atropine. Six patients underwent percutaneous pacing. None of the patients developed a new cardiac arrest during transportation. The average Glasgow Coma Scale score and heart rate upon arrival at the hospital were significantly greater than those at the scene. CONCLUSION: The present study showed the current status of patients with AVB who were transported by a doctor helicopter using registry data from the JDHR. The present findings suggest that a doctor helicopter could provide safe transportation for patients with AVB.

Analysis of the Activities of a Physician-Staffed Helicopter in the Coronavirus Disease 2019 Pandemic Phase.

OBJECTIVE: The purpose of this study was to investigate changes in the duration of activity of a physician-staffed helicopter emergency medical service (HEMS) in Eastern Shizuoka Prefecture before and during the coronavirus disease 2019 pandemic. METHODS: We retrospectively investigated the duration of dispatch activities from February 2020 to June 2021 (pandemic group, n = 1,032) and from April 2016 to January 2020 (control group, n = 3,054). RESULTS: There were no significant differences in the average age, percentage of male patients, interval from the request of HEMS dispatch to arrival, interval from arrival at the scene to leaving the scene, interval from leaving the scene to arrival at the hospital, or the ratio of requests for HEMS dispatch from the local fire department between the control and pandemic groups. In contrast, the interval from the first call to HEMS dispatch in the control group was significantly shorter than that in the pandemic group, and the ratio of requests for HEMS dispatch before contacting patients in the control group was significantly greater than that in the pandemic group. CONCLUSION: The interval from the first call to HEMS dispatch was prolonged in the COVID-19 pandemic period. However, the actual activity time of the HEMS was not affected.

Significance of medical intervention for non-traumatic hemorrhagic cardiac tamponade.

BACKGROUND: The outcomes of patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade are poor. PURPOSE: We retrospectively investigated the significance of medical intervention with pericardiocentesis and/or pericardiotomy for non-traumatic hemorrhagic cardiac tamponade. METHODS: From January 2013 to April 2021, we retrospectively reviewed the medical charts of all patients with cardiac arrest in a prehospital setting or emergency room due to cardiac tamponade confirmed by an ultrasound examination with or without an invasive procedure (pericardiocentesis and/or pericardiotomy) and computed tomography findings, including those obtained at autopsy imaging. The subjects were divided into two groups: the Intervention (+) group, which included subjects who underwent pericardiocentesis or pericardiotomy, and the Intervention (-) group, which included subjects who did not undergo pericardiocentesis or pericardiotomy. Variables were then compared between the two groups. RESULTS: There were 68 patients with non-traumatic cardiac tamponade. All three survival cases had witnessed collapse, and the initial rhythm was pulseless electrical activity (PEA).There were no statistically significant differences in the sex, age, means of transportation, bystander chest compression, electric shock, or adrenalineor FDP levels between the two groups.However, the number with witnessed collapse, PEA, rupture of the heart;the ratio of obtaining return of spontaneous circulation; and the survival ratio were significantly greater in the Intervention (+) group than in the Intervention (-) group. CONCLUSION: Based on the results of preliminary study, we hypothesized that invasive medical intervention for patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade might be useful for obtaining return of spontaneous circulation and a survival outcome, especially for patients with witnessed collapse with PEA as the initial rhythm.

An analysis of patients with acute aortic dissection who were transported by physician-staffed helicopter.

PURPOSE: The present study aimed to determine whether or not patients with acute aortic dissection (AAD) treated by the staff of a doctor helicopter (DH) service while being transported from the scene or for interhospital transportation obtained a favorable outcome. METHODS: We retrospectively investigated all patients with AAD who were transported by DH between January 2015 and December 2019 using the registry data of the DH control room of our hospital. RESULTS: One hundred five cases were enrolled in the present study. All patients were transported within 24 h from the onset. Male patients accounted for 55.2% of the study population, the average age was 71 years and the rate of Stanford A AAD was 51.4%. Regarding transportation, 61.6% of the patients underwent interhospital transportation, and 42.8% were transported to our hospital. All patients underwent drip infusion during transportation and 81.9% of the patients received drugs (e.g., depressors, pain killers and/or antiemetics). Two patients underwent tracheal intubation due to unconsciousness and profound shock with restless state, respectively. The systolic blood pressure after transportation to hospital was significantly higher in comparison to before transportation. No patients suffered cardiac arrest or showed a deterioration of vital signs. All patients were safely transported to the destination. CONCLUSION: The present study suggests the safety of using a Dr. Heli to transport AAD patients from the scene and for interhospital transportation, even after the onset.

A comparison of physician-staffed helicopters and ground ambulances transport for the outcome of severe thoracic trauma patients.

PURPOSE: We retrospectively investigated prognostic factors for severe thoracic trauma patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) and ground ambulance using the Japan Trauma Data Bank (JTDB). METHODS: This study was a retrospective analysis of the JTDB database. The study period was from January 2004 to May 2019. The subjects were divided into two groups, according to the type of transportation: the Heli group included cases transported by the HEMS, while the Ambulance group included cases transported by ground ambulance. RESULTS: During the investigation period, a total of 57,872 patients were enrolled as subjects, including 7238 in the Heli group and 50,634 in the Ambulance group. The average age, male ratio, average injury severity score (ISS), average revised trauma score (RTS) and survival ratio were significantly greater in the Heli group than in the Ambulance group. After performing a propensity score-matched analysis, there were no statistical differences concerning the age, sex, ISS, RTS between the two groups. However, the survival ratio in the Heli group remained greater than that in the Ambulance group. When variables that showed statistical significance in the univariate analysis were included in a multivariate analysis, the RTS, transport by the HEMS, age, ISS and female gender were identified as significant predictors of a survival outcome. The HEMS was significantly associated with an increased survival ratio (odds ratio: 1.69; 95% confidence interval: 1.51-1.88) compared with a ground ambulance. CONCLUSION: The present study showed that transport by the HEMS improved the survival rate compared to that by a ground ambulance for patients with severe thoracic trauma.

Experience Using a Forehead Continuous Deep Temperature Monitoring System During Air Evacuation.

OBJECTIVE: The present study describes the utility of a forehead continuous deep temperature monitoring system by the staff members of a doctor helicopter (DH). METHODS: A questionnaire survey was performed for all flight doctors who had used this system during transportation by the DH to assess its merits and demerits. RESULTS: The major benefits of this system were its easy usability, disposable nature, low labor cost, continuous demonstration of the deep temperature in a prehospital setting, and low invasiveness. However, drawbacks of this system include its cost; need for a power supply; need for a few minutes for calibration to obtain stable results of temperature, making it impossible to verify the effects of intervention for body temperature during a short flight; and lack of a detachable measuring pad for the forehead when a patient has an injury on the face or head and hyperhidrosis. In addition, the system's attached cables may hamper medical interventions. CONCLUSION: We reported the experience of DH staff using a forehead continuous deep temperature monitoring system in the prehospital setting. Further studies will be required to determine the indications for using such a system in the prehospital setting.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy.

BACKGROUND: The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents. CASE PRESENTATION: A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions. CONCLUSION: This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Clinical Investigation of Burn Patients Transported by Helicopter Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated the actual conditions of burn patients evacuated by helicopter in comparison to those evacuated by ground ambulance using the Japan Trauma Data Bank. METHODS: This study was a retrospective analysis of the data recorded in the Japan Trauma Data Bank between January 2004 and May 2019. After propensity score matching for the method of transportation, the survival rate was compared between the 2 groups. RESULTS: During the investigation period, there were 4,627 burn patients (helicopter group, n = 276; ambulance group, n = 4,351). After propensity score matching, there were no significant differences between the 2 groups in any of the assessed variables, and the survival rate did not differ to a statistically significant extent. CONCLUSION: After propensity score matching, the survival rate of the helicopter group did not appear to be superior to the ambulance group. Further prospective studies are needed to explore the proper indications for air transportation of burn patients, which could potentially improve outcomes.

Experience of the Usage of a Portable X-ray System.

OBJECTIVE: The purpose of this study was to introduce the use of a portable X-ray system by the staff members of a doctor helicopter (DH). METHODS: From January 11 to 18, 2019, we were given temporary access to a portable X-ray system. This period is defined as the investigation term. During the investigation term, a medical chart review was retrospectively performed for all patients who were transported by the DH. We investigated the variables between cases in which an X-ray study had been performed (X-ray group) and had not been performed (control group). RESULTS: Thirteen subjects were classified into the X-ray group, and 17 were classified into the control group. No X-ray studies were performed for patients who underwent interhospital transportation, and the proportion of cases involving patients with exogenous disease in the X-ray group was greater than that in the control group. CONCLUSION: We reported our experience of DH staff performing X-ray studies at the scene. Further studies are required to determine the indications for using portable X-ray systems in the prehospital setting.

Prognostic Factors in Trauma Patients Transported by Physician-Staffed Helicopter in Japan: An Investigation Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated prognostic factors for patients evacuated by the physician-staffed helicopter emergency medical service using the Japan Trauma Data Bank. METHODS: The study period was from January 2004 to May 2019. The subjects were divided into 2 groups according to the outcome: the survival group and the fatal group. RESULTS: A total of 19,370 patients were enrolled as subjects. There were 17,080 patients in the survival group and 2,290 in the fatal group. In a multivariate analysis of factors that showed statistical significance in a univariate analysis, the Revised Trauma Score, age, Injury Severity Score, Maximum Abbreviated Injury Scale (MAX-AIS) for the upper extremity (negative), year of helicopter dispatch, Japan Coma Scale, MAX-AIS for the head, MAX-AIS for the abdomen/pelvis, and MAX-AIS for the spine were identified as significant predictors of a fatal outcome . CONCLUSION: This is the first report to investigate the prognostic factors of patients evacuated by helicopter emergency medical service using the Japan Trauma Data Bank. The results suggest that physiological abnormality, age, traumatic anatomic abnormality (other than upper extremity abnormality), and year of helicopter dispatch may be prognostic factors.

The Significance of a Cooperative Medical System for Treating Decompression Illness on the Izu Peninsula in Japan.

INTRODUCTION: In 2011, our hospital on the Izu peninsula began to hold meetings to discuss how to manage patients with decompression illness (DCI) to establish a cooperative medical system. We retrospectively investigated the influence of these meetings and the changes subsequently effected. METHODS: A medical chart review was retrospectively performed to investigate all cases between January 2005 and December 2017 in which the transport of patients with DCI via a physician-staffed helicopter emergency medical service (HEMS) was attempted. The patients were divided into 2 groups: the preprogram group and the postprogram group. RESULTS: There were 63 patients in the preprogram group and 65 in the postprogram group. There were no cases in which a patient's symptoms deteriorated during transportation by the HEMS. The frequency of dispatch to the scene for direct evacuation in the postprogram group (86%) was greater than that in the preprogram group (74%), but the difference was not statistically significant (P=0.09). In the postprogram group, the duration of activities at the scene or the first aid hospital was significantly shorter in comparison to the preprogram group (P=0.01). CONCLUSIONS: This retrospective study revealed simultaneity between the introduction of the yearly meetings and a reduced duration of the HEMS staff's activity at either the scene or the first aid hospital.

A Smartphone Video Transmission System for Verification of Transfusion.

A physician-staffed helicopter emergency medical service called a doctor helicopter (DH) in Eastern Shizuoka was equipped with a smartphone video transmission system in April 2018. We herein report on the introduction of this system for the verification of transfusion in the DH. A 51-year-old man visited a local hospital after cutting his left neck himself. He was diagnosed with jugular vein injury and underwent compressive hemostasis. As he entered profound hemorrhagic shock, he underwent tracheal intubation, massive fluid resuscitation, and administration of 3 vasopressor agents to maintain circulation. The Eastern Shizuoka DH was requested to transport this patient. After making contact with the patient, the staff of the DH started prehospital transfusion. Because this was the first case of transfusion in a prehospital setting for our hospital, we held a meeting in which we used a smartphone video transmission system to verify the condition surrounding the transfusion in the DH. By reviewing the video record, we confirmed that the transfusion was performed safely and correctly in the prehospital setting. This smartphone video transmission system was useful for verifying the activity of the staff in the DH.

The Utility of a Portable X-ray System.

Fujifilm (Tokyo, Japan) developed a portable X-ray system called the CALNEO Xair. We herein report our experience in using this portable X-ray system at the scene after transportation by a doctor helicopter (DH). An explosion suddenly occurred while a 42-year-old man was handling toluene in a factory, causing his clothes to catch on fire. When the staff of a physician-staffed helicopter (DH) equipped with a portable X-ray system checked the man at the rendezvous point, he had second- and third-degree flame burns to > 70% of his total body surface area. A chest X-ray obtained using the portable X-ray system showed clear lung fields. A noninvasive carboxyhemoglobin monitor indicated a carboxyhemoglobin value of 6%. He was transferred to a special burn center by the DH. This is the first reported case in which a portable X-ray system was used to evaluate blast injuries in the prehospital setting. This system may be useful for performing prehospital medical treatment for blast injury victims.

Convulsion Treated by a Physician-Staffed Helicopter.

OBJECTIVE: There have been no reports focusing on patients with convulsion treated by a doctor helicopter (DH). We herein report the results of a retrospective analysis investigating the changes in patients' vital signs and clinical manifestations during transportation and the outcomes of treating convulsive patients using a government-funded medical DH. METHODS: We retrospectively investigated all of the patients with convulsion who were transported by the DH between January 2013 and December 2018. RESULTS: A total of 118 cases were enrolled in the present study. The average age was 32 years old, and most were men. Fifty cases showed remaining convulsion when the staff of the DH made contact with the subject. All subjects obtained a survival outcome. Regarding anticonvulsants administered, diazepam was the most frequently used followed by midazolam. The frequency of convulsion after transportation was significantly lower than that before transportation. The Glasgow Coma Scale and peripheral capillary oxygen saturation after transportation to a hospital were higher than before transportation. The heart rate after transportation to a hospital was lower than before transportation. CONCLUSION: The present study indicated the usefulness of a physician-staffed helicopter for treating convulsive patients at the scene.

Should Helicopters Transport Patients Who Become Sick After a Chemical, Biological, Radiological, Nuclear, and Explosive Attack?

The local fire department executed a training simulation for chemical and explosive incidents at a large sports facility. In this training simulation, a physician-staffed helicopter arrived at the request of the fire department and landed just outside the cold zone in the parking area. The doctor and nurse of the helicopter were escorted to a red area in the cold zone, which was selected based on the results of postdecontamination triage. After the patients had been treated, they were air medically evacuated to the base hospital. In the Tokyo subway sarin attack in 1995, St Luke's International Hospital admitted over 600 victims. During this incident, 23.2% of medical staff suffered secondary injury from sarin exposure. If air medial crews respond with subsequent postexposure effects during flight, an affected pilot could lose control of the helicopter, resulting in a fatal crash. Based on potential safety concerns for air medical and ground personnel, our recommendation would be that air medical helicopters not be dispatched to sites of chemical, biological, radiological, nuclear, and explosive incidents.