The Impact of the Coronavirus Disease 2019 Pandemic on Helicopter Emergency Medical Services.

The coronavirus disease 2019 pandemic has profoundly affected the Lombardy healthcare system. Although air transport of critical patients played a crucial role, there are still gaps in understanding how the pandemic impacted helicopter emergency medical services (HEMS). A retrospective observational analysis was performed using data from the regional emergency-urgency online portal. The investigation focused on patients airlifted by helicopter to the Lombardy emergency departments from January 1, 2019, to December 31, 2021. A total of 12,953 admissions to the emergency departments have been recorded (5,733 in 2019, 3,550 in 2020, and 3,670 in 2021). The monthly average of events changed significantly over the 3 years (2019 [477.7], 2020 [295.8], and 2021 [305.8]) (P < .001). Additionally, there was a notable increase in the percentage of severe cases with red triage codes in 2020 (28.9%) and 2021 (33.5%) compared with 2019 (19.9%). Moreover, the number of hospitalized patients increased in 2020 (39.9%) and 2021 (37.2%) compared with 2019 (27.7%). The HEMS documented a noteworthy decrease in mission numbers and an increase in patient clinical severity during the pandemic. Consequently, the HEMS might be allocated for specific roles in national pandemic plans during the alert phase activation, such as secondary transport between hospital facilities.

An Air Medical Approach to In-Flight Cardiac Arrest Management.

OBJECTIVE: Cardiac arrest during air medical transport is a complex and challenging issue, with unique factors such as limited physical space with restricted access to patients and equipment, small transport teams, limited resources, clinical isolation, effects of altitude, and the need for rapid decision making. The American Heart Association proposed 10 steps to improve outcomes of in-hospital cardiac arrest and serve as the framework for this article. This article aimed to explore these unique challenges and propose a contextual approach that might serve as the basis for improvement projects looking to improve outcomes for affected patients. METHODS: This article represents a narrative review of the subject to consolidate the issue of cardiac arrest in the air medical setting specifically. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension was used to guide the search strategy and methodology. The applicable items in the literature were selected through searches of the PubMed and Google Scholar databases. The Medical Subject Headings search terms used included "cardiopulmonary resuscitation" or "heart arrest" and "air ambulance" or "air medical transport,'' yielding 477 results. Screening for relevant results for inclusion was based on the relevance of the title or abstract. Articles not written in English or German or addressing commercial air transport were excluded. The reference lists of the included articles were searched for additional literature not included in the original search. RESULTS: Three distinct phases are arbitrarily identified by the authors, and the results are discussed under the following headings: pre-arrest, intra-arrest, and post-arrest phases. The pre-arrest phase is characterized by a wide array of concepts such as appropriate goals of care, advanced preparation and action, good clinical governance, patient assessment and handover, system design and ergonomics, sterile cockpit management, appropriate alarm management, and contingency planning in the case of failed resuscitation. The intra-arrest phase is characterized by the contextualization of the usual resuscitation approach, and specific recommendations for immediate nonresuscitative actions, history, hazards, help, airway, breathing, circulation, drugs, and reversible causes are suggested. The post-arrest phase highlights the vulnerable nature of the post-cardiac arrest patient in the air medical setting. Specific considerations regarding postresuscitation care and practitioner well-being are highlighted. CONCLUSION: This article outlines a systematic approach to various physical, clinical, mental, and systemic factors that can be used during various phases of the transport journey as well as the individual patient journey. This overview sensitizes individual clinicians or program directors to the factors needing consideration when looking to improve cardiac arrest patient outcomes.

Psychomotor Vigilance Testing on Neonatal Transport: A Western Australian Experience.

OBJECTIVE: This study aimed to assess whether undertaking retrieval was associated with fatigue independent of sleep and circadian disruption. It also aimed to assess the feasibility of routinely measuring the psychomotor vigilance test (PVT) on neonatal transport. Fatigue is associated with impaired clinician performance and safety. The association between shift work, sleep deprivation, and circadian disruption is well established. No studies have specifically assessed the independent effect of the retrieval environment on fatigue. METHODS: Medical and nursing staff of the neonatal retrieval team were prospectively recruited over a 12-month period. Simple reaction times (RTs) were recorded at the start and end of a day shift using a validated 3-minute PVT. RESULTS: The end-of-shift RT increased (not significant) by 6.38 milliseconds (95% confidence interval [CI], -2.17 to 14.92 milliseconds; P = .149) when retrieval was undertaken. A 1-millisecond increase in RT increased the odds of being in a subjective sleepy category by 0.57% (95% CI, 0.0036-0.0078; P < .001). Consuming caffeine during the shift increased the mean RT by 16.26 milliseconds (95% CI, 4.43-28.1 milliseconds; P < .01). CONCLUSION: The RT of participants exposed to the retrieval environment was not significantly increased. Further studies are needed to consolidate these results as well as to further assess longer-range air medical retrievals.

Flexible Fiber-Optic Scope Use in Retrieval Medicine: A Case Series.

OBJECTIVE: The use of flexible fiber-optic scopes is increasing across critical care specialities, but there is limited literature on their use in retrieval medicine. This study aims to describe a case series in which flexible fiber-optic scopes were used by New South Wales Ambulance Aeromedical Operations critical care teams. METHODS: A retrospective case series was performed in our service from January 1, 2019, to December 31, 2021. We searched our electronic medical retrieval database for the terms "aScope," "Awake Fibreoptic Intubation (AFOI)," "Fibreoptic Intubation (FOI)," and "Nasal Endotracheal Tube (ETT)" to identify when a flexible fiber-optic scope was used. RESULTS: There were 16 uses of flexible fiber-optic scopes during the study period. The most common procedure was awake nasal fiber-optic intubation, which was performed during 9 cases, 7 of which were successful. Other procedures performed included 4 cases of intubation through a supraglottic airway, 1 case of an asleep fiber-optic intubation, 1 case of flexible nasoendoscopy for upper airway assessment, and 1 case of fiber-optic bronchoscopy via tracheostomy. These procedures were performed by anesthetic, emergency and intensive care doctors. This case series describes 4 of these cases in more detail. CONCLUSION: This case series demonstrates a variety of procedural and diagnostic uses for flexible fiber-optic scopes in retrieval medicine. These procedures can have an important bearing on decision making and patient management. The training and clinical governance provided by our service in this skill appears to be safe and robust with high success rates of awake fiber-optic intubations.

Comparison of Interfacility Transfer of Critically Ill Pediatric Patients by Helicopter Versus Ground Ambulance in a Remote and Rural Domain.

OBJECTIVE: Since 2018, Thailand's helicopter emergency medical service (HEMS) has been used to transport critically ill pediatric patients from Tak Province's community hospitals to the tertiary care hospital. This article describes a pilot study to look at the feasibility of comparing mortality rates and complications during transport. METHODS: This retrospective pilot study used data from the medical records of the referring and receiving hospitals. Participants were critically ill patients under 18 years of age who were transferred between facilities using HEMS or ground emergency medical services (GEMS) between January 2018 and December 2022. HEMS transported 9 patients, whereas GEMS transported 52. RESULTS: The predominant age group was newborns. Respiratory-related conditions were the most common diagnoses. The majority of patients underwent intubation and displayed abnormal respiratory rates and levels of consciousness before flight. Approximately one third were hypotensive or required vasoactive drugs. Cardiac arrest requiring cardiopulmonary resuscitation was the most common significant complication during transport in the HEMS group (22.2%). Meanwhile, changing hospital destination because of an unstable patient condition was the most common complication during transport in the GEMS group (3.9%). Hypotension was the most common complication upon arrival at the receiving hospital in both groups (25% versus 8%). HEMS demonstrated shorter transport times. CONCLUSION: HEMS reduced transport times compared with GEMS. However, there was a higher incidence of cardiac arrest requiring cardiopulmonary resuscitation during transfer and hypotension upon arrival.

Flying Doctor Services in Sarawak: A Medical Frontline Experience.

Malaysia has a 34.3 million population, with 40% residing in rural areas. Since gaining independence, the Malaysian government put a tremendous focus as well as resources in improving the health care services with the aim of improving the health status of Malaysians. The Ministry of Health is the main stakeholder in ensuring quality of services, accessibility, and equity in providing health care to the community. Unfortunately, some rural areas in the state of Sarawak are beyond reachable via land or water transportation. Hence, a flying doctor service was introduced in the state of Sarawak in 1973 for this purpose. However, the quality of care is still limited because of various reasons and challenges faced. Nevertheless, efforts in improving the health care status of the rural continue as we aim to leave no one behind.

Recent Outcomes Research in Helicopter Emergency Medical Services: A Scoping Review of Publication Year 2023 Additions to the Helicopter Outcomes Assessment Research Database.

OBJECTIVE: The purpose of this scoping review was to identify and characterize helicopter emergency medical services (HEMS) outcomes literature from 2023, with the goal of describing updates to the Critical Care Transport Collaborative Outcomes Research Effort HEMS Outcomes Assessment Research Database (HOARD). METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, a multireviewer approach was used to source and review articles published or in preprint databases from 2023. The articles included assessed a patient-centered outcome for HEMS versus a non-HEMS control group. Article characteristics included the journal impact factor (JIF), diagnostic group (trauma or nontrauma), and geographic origin. Categoric analyses comparing 2023 studies with HOARD studies from the previous decade (2013-2022) were executed with the Fisher exact test; nonnormal JIF data were described using median and interquartile range and analyzed (vs 2013-2022) with rank sum testing. RESULTS: Of the initial records (N = 4,486), 4,410 were screened out, leaving 76 for full-text review. Of these, 58 were discarded, and 18 were classified as eligible for addition to HOARD. Most studies (14/18, 78%) focused on trauma, and an equally high proportion (14/18, 78%) came from North America. The median JIF was 2.4 (interquartile range, 1.2-3.6). Compared with HOARD studies from the previous decade, 2023 studies were similar with respect to diagnostic focus (P = .779), geographic origin (P = .171), and JIF (P = .531). CONCLUSION: This scoping review provides information on 18 HEMS outcomes studies new to the evidence base in 2023.

Patients With Near Arrest Induced by Foreign Body Airway Obstructions Treated by a Physician-Staffed Helicopter.

Acute airway obstruction, whether partial or complete, requires immediate intervention to prevent fatal outcomes. An 81-year-old man with a history of pneumonia experienced respiratory distress after attempting to swallow a large piece of meat. Despite attempts by his daughter, back blows and abdominal thrusts failed to dislodge the obstruction, and he collapsed, prompting an emergency call. Upon the arrival of the emergency medical team, the patient was conscious with good oxygen saturation but deteriorated during transport, becoming unresponsive and unable to cough. Upon assessment by the doctor helicopter team, the patient's condition was critical with low oxygen saturation and unstable vital signs. Using a laryngoscope, the team identified a large meat fragment near the vocal cords and successfully removed it, relieving the obstruction. The patient's respiratory distress improved, and he was transported to the hospital without the need for intubation. Further examination at the hospital revealed sinus tachycardia and lung abnormalities on a computed tomography scan but no significant abnormalities in blood tests. The patient was admitted for observation and received antibiotics for prophylaxis. He recovered well, with no further need for oxygen by the second day and was discharged on the fourth day, highlighting the importance of prompt intervention in airway emergencies.

The Impact of Location and Asset Type on the Success of Advanced Airway Management in a Critical Care Transport Environment.

OBJECTIVE: Advanced airway management (AAM) is a critical component of prehospital critical care. Airway management in flight can be more challenging because of spatial, ergonomic, and environmental factors. This study examines the frequency of in-flight intubation (IFI), first-pass success (FPS) rates, and definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) across different locations of airway management. METHODS: We conducted a retrospective database analysis of all patients transported between January 2016 and July 2021 who received AAM from a single air medical service. Patient records were reviewed for location of intubation, patient characteristics, and FPS and DASH-1A rates. The primary outcome was the frequency of IFI. The secondary outcomes included FPS and DASH-1A rates by location and type of transport asset. RESULTS: During the study period, 473 patients required AAM. Three percent (15/473) of patients were intubated in an in-flight setting, 28% (130/473) were intubated on scene, and 70% (328/473) were intubated in a health care facility. The primary reason for IFI was unanticipated cardiac arrest or clinical deterioration. The overall FPS rate was 69% (328/473), and the DASH-1A rate was 49% (194/399). Based on the location of AAM, the FPS and DASH-1A rates were the lowest for on-scene intubations (56% [74/130] and 27% [20/74], respectively). Most of the on-scene AAM took place with rotor wing flight crews. CONCLUSION: Airway management occurs infrequently in an in-flight setting and is necessary because of patient deterioration or cardiac arrest. Based on our results, we identified opportunities for targeted AAM quality improvement and clinical governance.

Simulation-Based Learning to Assess and Improve Critical Care Transport Team Members' Knowledge of Pediatric Intubation: A Quality Improvement Project.

OBJECTIVE: The care of critically ill neonatal and pediatric patients requiring transport is optimized by using specialty transport teams. Research demonstrates that training is best accomplished through routine simulation. At the project site, no simulation-based learning is provided to critical care transport team members. This project aimed to implement a simulation-based learning program to improve the knowledge and self-competency of neonatal and pediatric critical care transport team members. METHODS: Team members participated in two 9-week paired pediatric simulations that incorporated intubation and mechanical ventilation. Testing was conducted through a knowledge test and self-competency survey completed before and after both simulations and a performance checklist for each simulation. RESULTS: There was a statistically significant increase in knowledge test scores from the baseline knowledge test to each subsequent test (P ≤ .001, P = .002, and P ≤ .001). For self-competency, there was a statistically significant increase from the first survey to the second (P ≤ 0.001) and fourth (P ≤ .001). From the first to the second simulation, there was a statistically significant increase in performance (P ≤ .001). CONCLUSION: Paired simulation-based learning allows for the assessment and improvement of team members' knowledge. Future research should focus on how this improved knowledge translates to patient care.

Proceedings: Sixth International Futures of Aviation Medicine Symposium.

In June 2024, leaders in aviation medicine from across the United States, Canada, and Europe met for the sixth Leonardo Helicopters/Association of Critical Care Transport: The Path to High Reliability Futures of Aviation Medicine Symposium in Miami, FL. The symposia, now held every few years, grew from the 2003 Air Medical Leadership Congress: Setting the Healthcare Agenda for the Air Medical Community. The meetings' goal is to gather leaders to distill, debate, and synthesize the state of the science while identifying, refining, and outlining conditions facilitating favorable evolution in civilian aviation medicine. Structured as thematic panel presentations followed by interactive all-attendee roundtable discussions, the gatherings build and expand an international network of thought leaders and proven doers. Meeting attendees have a common goal-accelerating learning and practice among early and developed systems moving toward a shared worldwide agenda for the future of aviation transport medicine.

How to Handle In-Flight Death in International Patient Repatriation and Air Ambulance Operations.

In-flight cardiac arrest is a rare event that occurs at a rate of approximately 1 event in 3.8 to 4.7 million commercial airline passengers and at a rate of approximately 1 event in 1,500 to 3,000 patients transported by fixed wing international air medical transport. Only 13% to 19% of victims of in-flight cardiac arrest can be successfully resuscitated. The arrival of an aircraft with a deceased patient/passenger on board triggers a country-specific procedure that focuses on public health and medicolegal considerations. In most jurisdictions, these procedures are detailed in the respective national Aeronautical Information Publication, which are commonly based on the International Civil Aviation Organization International Standards and Recommended Practices, Annex 9 to the Convention on International Civil Aviation. Awareness among medical and flight crews on such procedures will support appropriate documentation of the event and enable effective cooperation with the relevant local authorities.

Quality and safety in prehospital airway management - retrospective analysis of 18,000 cases from an air rescue database in Germany.

BACKGROUND: Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. METHODS: This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. RESULTS: Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). CONCLUSIONS: Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. TRIAL REGISTRATION: The study was registered in the German Register for Clinical Studies (number DRKS00028068).

Equity in the provision of helicopter emergency medical services in the United Kingdom: a geospatial analysis using indices of multiple deprivation.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) in the United Kingdom (UK) are provided in a mixed funding model, with the majority of services funded by charities alongside a small number of government-funded operations. More socially-deprived communities are known to have greater need for critical care, such as that provided by HEMS in the UK. Equity of access is an important pillar of medical care, describing how resource should be allocated on the basis of need; a concept that is particularly relevant to resource-intensive services such as HEMS. However, the Inverse Care Law describes the tendency of healthcare provision to vary inversely with population need, where healthcare resource does not meet the expected needs in areas of higher deprivation. It is not known to what extent the Inverse Care Law applies to HEMS in the UK. METHODS: Modelled service areas were created with each small unit geography locus in the UK assigned to its closest HEMS operational base. The total population, median decile on index of multiple deprivation, and geographic area for each modelled service area was determined from the most recently available national statistics. Linear regression was used to determine the association between social deprivation, geographic area, and total population served for each modelled service area. RESULTS: The provision of HEMS in the UK varied inversely to expected population need; with HEMS operations in more affluent areas serving smaller populations. The model estimated that population decreases by 18% (95% confidence interval 1-32%) for each more affluent point in median decile of index of multiple deprivation. There was no significant association between geographic area and total population served. CONCLUSION: The provision of HEMS in the UK is consistent with the Inverse Care Law. HEMS operations in more deprived areas serve larger populations, thus providing a healthcare resource inversely proportional with the expected needs of these communities. Funding structures may explain this variation as charities are more highly concentrated in more affluent areas.

Utilisation and outcomes of a mobile (ambulance and air transport) venovenous extracorporeal membrane oxygenation (VV-ECMO) program in Poland during the COVID-19 pandemic - a retrospective, two-centres, case-series study.

INTRODUCTION: Many patients required mechanical ventilation support due to severe COVID-19 pneumonia. A significant proportion of mechanically ventilated patients also required venovenous extracorporeal membrane oxygenation (VV-ECMO) due to refractory hypoxemia. A high demand for VV-ECMO support during the pandemic was challenging due to many factors, including limited resources and lack of established transfer protocols. This study aims to present the organisation and outcomes of a mobile VV-ECMO program in two high-volume centres in Poland during the COVID-19 pandemic. MATERIAL AND METHODS: This retrospective, two-centre case series study, which lasted 36 months, was conducted between March 10, 2020, and January 31, 2023. The data of all patients transferred using venovenous extracorporeal membrane oxygenation (VV-ECMO) were analysed, including five women in the perinatal period with severe respiratory failure attri-buted to the COVID-19 virus. The analysis encompassed baseline patient demographics, Sequential Organ Failure Assessment (SOFA) scores, admission laboratory parameters, ECMO therapy, duration of mechanical ventilation, and patient survival to ICU discharge. RESULTS: We assessed 86 patients who met the ELSO inclusion criteria and were transported during VV-ECMO support. Mortality in the analysed group was high (80.3%). Despite high mortality, VV-ECMO appeared to be a safe procedure in COVID-19 patients with severe ARDS. No complications were noted in more than half of the analysed procedures. Despite the above, many severe complications were observed, including stroke or cerebral haemorrhage (9.8%) and limb or gut ischemia (1.6%). The most common problems co-existing with VV-ECMO treatment were bleeding complications (34.4%). CONCLUSIONS: The ICU mortality rate among patients requiring VV-ECMO for COVID-19 in high-volume ECMO centres was high but not associated with the type of transportation.