Helicopter Emergency Medical Helicopter Emergency Medical Services…Services…

Not Just For Trauma AnymoreNot Just For Trauma Anymore

Deb Funk, M.D., FACEP, NREMT-PDeb Funk, M.D., FACEP, NREMT-P

Medical Director, Life Net of NYMedical Director, Life Net of NY

Assistant Professor, Department of Emergency Medicine, Assistant Professor, Department of Emergency Medicine, Albany Medical CollegeAlbany Medical College

Emergency Medical Services…Emergency Medical Services…not just a fast ride with lights and not just a fast ride with lights and

sirens anymoresirens anymore

Emergency Medical Emergency Medical Technicians…not just ambulance Technicians…not just ambulance

drivers anymoredrivers anymore

Today’s Reality…Today’s Reality… The practice of medicine in many environments has The practice of medicine in many environments has

changedchangedFinancial issuesFinancial issuesStaffing shortagesStaffing shortages

The organization of health care has changedThe organization of health care has changedConsolidation of servicesConsolidation of servicesCreation of health care systemsCreation of health care systemsFiscal responsibility Fiscal responsibility

Mission profiles of hospitals, ground based EMS and Mission profiles of hospitals, ground based EMS and air medical services have changedair medical services have changedTeam approach to provide health care to an individual in Team approach to provide health care to an individual in

crisiscrisis

History of Air Medical Transport History of Air Medical Transport in the United Statesin the United States

11stst reported air transport of a patient in 1915 reported air transport of a patient in 1915French pilot evacuated a Serb in an unmodified fighter French pilot evacuated a Serb in an unmodified fighter

planeplane Through progressive conflicts, airplane evacuation Through progressive conflicts, airplane evacuation

of injured/ill more prominentof injured/ill more prominent First medical use of helicopter in 1944 in BurmaFirst medical use of helicopter in 1944 in Burma First large scale medical evacuation in Korea First large scale medical evacuation in Korea

(Sikorsky with outboard stretchers)(Sikorsky with outboard stretchers) UH-1H “Huey” central to medical care in VietnamUH-1H “Huey” central to medical care in Vietnam This approach reduced mortality and came to the This approach reduced mortality and came to the

attention of the American publicattention of the American public

Civilian Adaptation Civilian Adaptation

Early 1970’s federally funded pilot projects to Early 1970’s federally funded pilot projects to study feasibilitystudy feasibilityTenuous economic viabilityTenuous economic viabilityNeed to dedicate to medical configurationNeed to dedicate to medical configurationNeed for integration into ground EMS systemsNeed for integration into ground EMS systems

Civilian Law Enforcement/Fire Agencies Civilian Law Enforcement/Fire Agencies developed aviation componentsdeveloped aviation componentsOccasionally provided medical transportOccasionally provided medical transportSome pursued dedicated air medical programsSome pursued dedicated air medical programs

Maryland State PoliceMaryland State PoliceLA County Fire DeptLA County Fire Dept

Development in Civilian WorldDevelopment in Civilian World

Hospital BasedHospital BasedMost commonMost commonAircraft is leased from vendor or owned by hospitalAircraft is leased from vendor or owned by hospitalFirst in Denver 1972First in Denver 1972

Second Generation in early 1980’sSecond Generation in early 1980’sIncreasing federal interest due to costIncreasing federal interest due to costRole expanded from trauma to neonatal, OB, cardiacRole expanded from trauma to neonatal, OB, cardiac

Third Generation in mid-1980’sThird Generation in mid-1980’sFocus on safety, and cost effectivenessFocus on safety, and cost effectiveness

Current Trends in AeromedicineCurrent Trends in Aeromedicine 30+ years of helicopter transport30+ years of helicopter transport USA - Over 200 hospital based programsUSA - Over 200 hospital based programs 100,000+ patients transported annually100,000+ patients transported annually ““Brings the hospital” to the patientBrings the hospital” to the patient

Review of Ground EMS Review of Ground EMS DevelopmentDevelopment

Ground based EMS developed also as a result of Ground based EMS developed also as a result of wartime experienceswartime experiences

Multiple models of systemMultiple models of systemPrivate contractorPrivate contractorFD basedFD basedPrivate, for profit servicePrivate, for profit serviceMunicipal third serviceMunicipal third service

Multiple levels of provider-regionally dependentMultiple levels of provider-regionally dependentFirst Responders/Emergency Medical Technicians (BLS)First Responders/Emergency Medical Technicians (BLS)Intermediate/Paramedic (ALS)Intermediate/Paramedic (ALS)Specialty Care ParamedicSpecialty Care Paramedic

Integration of Ground and Air Integration of Ground and Air EMSEMS

Team approachTeam approach EducationEducation ProtocolsProtocols Quality AssuranceQuality Assurance

Indications for Air TransportIndications for Air Transport

TimeTimeDecrease time to definitive careDecrease time to definitive careDecrease out of hospital timeDecrease out of hospital time

TerrainTerrainOvercome environmental obstaclesOvercome environmental obstaclesOverfly traffic gridlockOverfly traffic gridlock

TalentTalentDelivery of highly skilled care to patients prior Delivery of highly skilled care to patients prior

to/during transportto/during transport

Air Medical TriageAir Medical Triage

>1,000,000 patients transported by >1,000,000 patients transported by helicopter since 1972 by nearly 200 helicopter since 1972 by nearly 200 programsprograms

Roughly 30/70 split scene/interfacilityRoughly 30/70 split scene/interfacility Triage of patients to receive air transportTriage of patients to receive air transport

Intend for majority of seriously ill/injured Intend for majority of seriously ill/injured patients get appropriate transportpatients get appropriate transport

Assumes a certain over-triage rate Assumes a certain over-triage rate

Practical Considerations: Practical Considerations: Method of TransportMethod of Transport

Optimal time dictated by patient’s Optimal time dictated by patient’s illness/injuryillness/injury

Distance, geography and trafficDistance, geography and traffic Availability of definitive care at local Availability of definitive care at local

hospitalshospitals Carrier and personnel availabilityCarrier and personnel availability Weather conditionsWeather conditions Cost Cost

Considerations: TraumaConsiderations: Trauma

Disease of time: minutes make a differenceDisease of time: minutes make a difference ACS/COT advocates that any seriously ACS/COT advocates that any seriously

injured patient be primarily treated in a injured patient be primarily treated in a trauma centertrauma centerAir medical transport based upon local factorsAir medical transport based upon local factors

Interfacility transport of seriously injured Interfacility transport of seriously injured patientpatientUse of helicopter based on time/terrain/talentUse of helicopter based on time/terrain/talent

Considerations: Non-TraumaConsiderations: Non-Trauma

Variety of medical/surgical conditionsVariety of medical/surgical conditions Time/Terrain/TalentTime/Terrain/Talent May benefit from specialty team May benefit from specialty team

(OB/NICU/PICU)(OB/NICU/PICU) Interfacility most commonInterfacility most common Scene may be appropriateScene may be appropriate

Contraindications to Air Contraindications to Air TransportTransport

Terminally ill with no correctable medical Terminally ill with no correctable medical problemsproblems

Cardiac arrest without SROCCardiac arrest without SROC Patients likely to die enroute, if in a facility Patients likely to die enroute, if in a facility

capable of resuscitationcapable of resuscitation Patients in active labor if delivery expected Patients in active labor if delivery expected

during transportduring transport Patients prone to psychotic/violent behavior Patients prone to psychotic/violent behavior

(without appropriate restraint)(without appropriate restraint)

Utilization ReviewUtilization Review

Prospective ScreeningProspective ScreeningDifficult based on limited info and time constraintsDifficult based on limited info and time constraints

Retrospective ReviewRetrospective ReviewChart review of outcome, procedures Chart review of outcome, procedures

performed,severity of illness, other subjective performed,severity of illness, other subjective parametersparameters

Follow UpFollow UpFeedback to callerFeedback to callerRevision of criteria as appropriateRevision of criteria as appropriate

Case 1Case 1

Grandpa and Little Johnnie were involved in a Grandpa and Little Johnnie were involved in a high speed head on MVC 5 miles from Nowhere.high speed head on MVC 5 miles from Nowhere.

Grandpa is on coumadin and has a tender, Grandpa is on coumadin and has a tender, distended abdomen. His HR is 120distended abdomen. His HR is 120

Johnnie is unconscious with an obvious skull Johnnie is unconscious with an obvious skull fracture. His jaw is clenched.fracture. His jaw is clenched.

20 min drive to community hospital 20 min drive to community hospital 20 min flight to trauma center (60min drive)20 min flight to trauma center (60min drive)

Case 1 DiscussionCase 1 Discussion

Johnnie needs an airway Johnnie needs an airway and a pediatric and a pediatric neurosurgeonneurosurgeon

Determine quickest way to Determine quickest way to airwayairway HEMS vs community hospitalHEMS vs community hospital Never wait on scene if Never wait on scene if

packagedpackaged Definitive care at peds Definitive care at peds

trauma centertrauma center

Consideration for automatic Consideration for automatic standbystandby

PEDIATRIC MAJOR TRAUMA 1. Pulse greater than normal range for

patient’s age2. Systolic blood pressure below normal

range3. 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 145. penetrating injuries of the trunk, head,

neck, chest, abdomen or groin.6. two or more proximal long bone fractures7. flail chest8. 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 paralysis10. amputation (except digits)

Case 1 DiscussionCase 1 Discussion

Grandpa needs blood Grandpa needs blood products and a products and a surgeonsurgeon

Determine most Determine most appropriate facilityappropriate facilityKnow local capabilitiesKnow local capabilitiesStabilization vs Stabilization vs

primary transport to primary transport to trauma centertrauma center

Consider med controlConsider med control

ADULT MAJOR TRAUMA 1. GCS less than or equal to 132. Respiratory Rate less than 10 or more

than 29 breaths per minute3. Pulse rate is less than 50 or more than

120 beats per minute4. Systolic blood pressure is less than

90mmHg5. Penetrating injuries to head, neck, torso

or proximal extremities6. Two or more suspected proximal long

bone fractures7. Suspected flail chest8. Suspected spinal cord injury or limb

paralysis9. Amputation (except digits)10. Suspected pelvic fracture11. Open or depressed skull fracture

2 patients=2 aircraft2 patients=2 aircraft

Case 2Case 2

Jake narrowly escapes from his burning Jake narrowly escapes from his burning apartment but suffers 60% second degree apartment but suffers 60% second degree burns.burns.

20 min drive to community hospital20 min drive to community hospital 20 min flight to trauma center20 min flight to trauma center 60 min flight to burn center60 min flight to burn center

Case 2 DiscussionCase 2 Discussion

Jake may need airway Jake may need airway protectionprotection

Definitive care at burn Definitive care at burn centercenter

Consideration for non Consideration for non burn injuriesburn injuries

CRITICAL BURNS1. Greater than 20% Body Surface Area

(BSA) second or third degree burns2. Evidence of airway/facial burns3. 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 3Case 3

Mrs. Brown had chest pain and ST elevation in Mrs. Brown had chest pain and ST elevation in inferior leadsinferior leads

20 min drive to community hospital20 min drive to community hospital 30 min flight to STEMI center (70min drive)30 min flight to STEMI center (70min drive)

Case 3 DiscussionCase 3 Discussion

Time to reperfusionTime to reperfusion 2004 AHA/ACC 2004 AHA/ACC

guidelinesguidelines Consideration of Consideration of

destinationdestinationLocal protocolLocal protocolMed controlMed control

CRITICAL MEDICAL CONDITIONS

1. Suspected Acute Myocardial Infarction

a. Chest pain, Shortness of breath or other symptoms typical of a cardiac event

b. 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 4Case 4

Mr. George has right arm and leg weakness Mr. George has right arm and leg weakness with slurred speech. Last normal 30min with slurred speech. Last normal 30min ago.ago.

20 min drive to community hospital20 min drive to community hospital 30 min flight to Stroke Center (70min drive)30 min flight to Stroke Center (70min drive)

Case 4 DiscussionCase 4 Discussion

Stroke is extremely time Stroke is extremely time dependentdependent 3hr window for IV TPA3hr window for IV TPA 6hr window for IA TPA6hr window for IA TPA Endovascular interventionEndovascular intervention

Most appropriate Most appropriate destinationdestination Patient factorsPatient factors TimingTiming Med controlMed control

CRITICAL MEDICAL CONDITIONS1. Suspected acute strokea. Positive Cincinnati Pre-Hospital

Stroke ScaleTotal 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 CriteriaNYS HEMS Utilization Criteria

Standard criteria described in Policy 05-05Standard criteria described in Policy 05-05Who callsWho callsWhen to callWhen to callWhen to cancelWhen to cancel

Specific local differences acknowledgedSpecific local differences acknowledged Education tool in developmentEducation tool in development

““Specific Local Differences”Specific Local Differences”

HEMS must be integrated into current EMS HEMS must be integrated into current EMS and hospital systemand hospital system

Requires cooperative preplanningRequires cooperative preplanning Demands ongoing reviewDemands ongoing review

SummarySummary

The practice of medicine evolvesThe practice of medicine evolves Consolidation of specialty services Consolidation of specialty services

continuescontinues Considerations for air medical transport Considerations for air medical transport

may be changingmay be changing Cooperative plans are imperative for a Cooperative plans are imperative for a

successful systemsuccessful system

Questions?Questions?