State of Alaska Aeromedical Physician Training Course

1
State of Alaska Aeromedical Physician Training
Course
Welcome to the
2
Course Objectives

• Understanding of air physiology
• Describe patient management in the
  aeromedical setting
• Recognize anticipate problems common in the
  aeromedical setting
• Dispatching considerations
• Sending and receiving considerations

3
History of Aeromedical Transports
International USA Alaska
4
The first AlaskanAeromedical Transport Training
Course 1980

• 120 hours of classroom training
• Focused on aircraft environment
• Three part exam
• Practical
• Written
• Oral

5
Federal Aviation Regulations

• They govern all civil aviation operations
• FAR Part 91 (general operating flight rules)
• FAR Part 135 (air taxi / commercial)
• Violation may result in removal of certification

6
Effect of Altitude on Barometric Pressure
10, 000 feet
523 mm Hg
Sea Level
760 mm Hg
Earth
7
Boyles Law

• The volume of a gas will varies inversely with
  pressure, given the temperature stays the same.
• Aeromedical Considerations
• Air splints
• Air mattress, mast suit, etc.
• Air in IV tubing drip chambers
• Endotracheal tube cuffs?

8
Conditions in which barotrauma may be dangerous

• Pneumothorax, Mediastinal, pericardial air
• URI with sinusitis, otitis media, mastoiditis
• Penetrating eye injury
• Diaphragmatic hernia
• Small bowel obstruction
• Recent Surgery
• Gas-filled abscess or cyst, Gas gangrene
• Following scuba diving

9
Daltons Law

• The total pressure of a gas mixture is the sum of
  the individual partial pressures of all the gases
  in a mixture.
• Aeromedical Considerations
• Pa02 decreases

10
Another Look at Daltons Law
10, 000 ft. 560 mm Hg
Partial Pressure of oxygen 118 21 of 560
118
21
Sea Level 760 mm Hg
21
Partial Pressure of oxygen 160 21 of 760
160
11
Charles Law

• The volume of a gas will vary directly with the
  absolute temperature, given the mass and pressure
  stay the same.
• Aeromedical Considerations
• Gas filled medical equipment increase size when
  warmed

12
Henrys Law

• The amount of gas dissolved in a solution is
  directly proportional to the pressure of the gas
  over the solution.
• Aeromedical Considerations
• Scuba Divers - Must fly sea level

13
Other Gas Laws

• Other Gas Laws
• Grahams Law - rate of diffusion
• Guy Lussacs Law - pressure increase
• Poiseulles Law - volume pressure gradient

14
Altitude affects theA-a GRADIENT

• Definition
• The difference in partial pressure of oxygen in
  the alveolar gas spaces and the pressure in the
  systemic arterial blood.
• A-a Gradient (Barometric Pressure - 47) times
  FIO2 - (PaCO2 /0.8) - PaO2

15
A-a Gradient What is the Aeromedical
significance?
Pulm Physiology

• Sea level
• 760 mmHg - 47 713
• (times the of O2) 21 150
• minus CO2 / Resp
• quotient 50 mm Hg
• PaO2 100 (Predicted)

10,000 feet 560 mmHg - 47 513 (times the of
O2) 21 108 minus CO2 / Resp quotient 50 mm
Hg PaO2 58 (Predicted)
16
Four types of Hypoxia

• Hypoxic hypoxia
• Anemic hypoxia
• Stagnant hypoxia
• Histoxic hypoxia

17
Causes ofHystoxic Hypoxia

• Drugs
• Prescriptive recreational
• Alcohol
• one ounce 2000 feet
• Cigarettes
• Three consecutive 8000 feet

18
REVIEW -CELLULAR RESPIRATION
Cell Mitochondria
Protein, Fat, or Glucose (C6 H12 O2)
Electron Transport Chain
ATP
2 Pyruvate Acid
Kreb Cycle
1/2 O2 2 Hydrogen two electrons Makes Water
CO2
ATP
CO2
O2 function discard electron waste after ATP
synthesis CO2 this is the cell waste product.
19
ELECTRON TRANSPORT CHAINDrugs, alcohol,
Smoking affect the Cytochrome

• Located in the Cell Mitochondria

Fe.S
FMN
Fe.S
Cytochromes
Q
Cyt b
Fe.S
Cyt c1
Cyt c
Cyt a
Cyt a3
Cytochrome, is a protein with a heme group.
1/2 O2
20
Factors affecting hypoxia

• Altitude
• Rate of Ascent
• Physical Fitness
• Physical Activities
• Drug Medications
• Individual Variations
• Alcohol
• Smoking

21
Plane Characteristics

• There are basic physical features similar to
  all planes.
• Basic principles of flight similar in all planes
• center of gravity, lift, drag, propulsion.
• There are several physical characteristics that
  individualize planes

22
Characteristics That Vary Among Planes

• Pressurized?
• Door dimensions
• Passenger capability--including flight crew
• Range
• Cabin length and height
• Cruise speed
• Electrical requirements--is it available?
• Runway consideration--length surface type
• Payload
• Built in medical unit

23
Disadvantages of Pressurized Aircraft

• Potential for rapid decompression
• (Typically commercial airlines fly at 30,000 to
  36,000 feet. Cabin pressure typically 5,000 to
  8,000).
• More money Plane and fuel
• Requires a longer runway
• Usually requires a paved runway

24
Disadvantages of Unpressurized Aircraft

• Air pressure fluctuates in
• Body cavities
• Air filled tubes (i.e. Mast pants)
• ET Tubes?
• Increase patient discomfort
• Altered effectiveness of medical equipment

25
Typical AK Medevac Aircraft

• Cessna 185, 206 or 207
• DeHavilland Beaver
• DeHavilland Otter
• Grumman Goose
• Piper Cub
• Piper Chieftan (Navajo)
• Cessna Conquest
• Boeing 737

26
Factors that Affect the Decision to Transport

• Primary Principle--Do no further harm
• Know indications for transfer
• Transfer agreements
• Transfer protocols
• Stabilize patient
• Transfer with skilled personnel and
• adequate adjunctive equipment

27
Overview of the Process of initiating a Medevac

• 1) Planning
• 2) Inventory of resources equipment
• 3) Medical control
• 4) Decision to transfer
• 5) Factors affecting transport
• 6) Communication -- Dispatch / Hospital
• 7) Communication -- Pilot

28
Planning Steps

• Assess patient
• Escorts available
• Escorts level
• Required equipment
• Types of Aircraft
• Landing conditions
• Number of patients
• Condition of patients

• Notification
• Receiving community
• Aircarrier
• Family members
• Pre-Transport Records
• Clinic or ambulance
• Insurance info
• Family contact number

29

Clinic / Medevac Personnel Prepare, Practice,
Educate
A Successful Medevac startsbefore the patient
gets ill.
Medical Control Establish protocols, Educate
Dispatch / Pilot Know what to anticipate
30
Pilot Weather Concerns

• Icing
• Turbulence
• Wind direction intensity for take-off
• Weather at landing community
• Extra fuel needed due to strong winds

The Pilot has the final word on weather.
31
Inventory Your Community Resources

• Airfields
• Air carriers
• Types of aircraft
• Escort qualifications
• Medical equipment available

32
Rescue vs Medevac
33
State of AlaskaResources Available for Rescue
Operations

• Alaska State Troopers
• U.S. Coast Guard
• MAST
• Alaska Air National Guard
• Local Army Guard

34
Decision to Transfer Based on Matching
PATIENT
Medevac Aircraft
Escort
Training level
1) ALS or BLS 2) Critical Care 3) Specialty
35
Transport with Caution

• Diving
• Gas Gangrene
• Pneumothorax
• Hypoxia
• Cardiac
• Wired Jaw
• Anemia
• Recent Abdominal Surgery

36
Rural Physician Medical Decision to Transfer

• Decision is made based on
• Weather
• Plane availability
• Staff availability and skill level
• Type of patient (pediatric, OB)
• Remember The rural physician is taking care of
  the patient with out the current technological
  luxuries. Like CT scans, etc

37
Rural Physician Medical Decision to Transfer

• Conflicts arise when the city doctor request
  you fix the problem. Not understanding the
  diagnostic, staffing, and equipment limitations
  of the rural area.
• Education of referring physician may be necessary
  to avoid conflict.

38
Rural Physician Medical Decision to Transfer

• At times the patient stops at another community
  due to weather restrictions.
• This new health care person may alter your
  initial plan of care. Communication is the key
  to preventing a disaster.

39
Rural Physician Medical Decision to Transfer

• How long would you keep a patient in a remote
  area with out
• A surgeon
• Advanced lab capabilities
• CT scan
• or Ultrasound
• Knowing you only have two flights a week.

40
Rural Physician Medical Decision to Transfer

• Limitations in staff and supplies may force
  medical triage decisions.
• Triage
• Salvageable vs the non-salvageable.
• The sickest salvageable patient to town.

41
Rural Physician Medical Decision to Transfer

• Realize some people choose to stay in the rural
  area AMA.
• However, they may change their mind.
• Now, you have a sick person and may not have the
  supplies to take care of them.
• Example Pre-eclampsia at a doorstep delivery.

42
Dispatch / Hospital

• Dispatch
• Never pressure the pilot into a flight.
• Inform pilot if patient weight excessive or
• sea-level cabin needed
• Never, never, never, tell the pilot the patient
  will die unless he flys
• Hospital
• Know names of contact people
• Ask for patient follow-up

43
Aircraft Orientation Prior to a flighthave the
pilot discuss the following

• ELT (Not to be confused with a BLT)
• Survival Gear
• Fire Extinguisher
• Flotation Devices
• Emergency Exit Operation
• Oxygen Storage
• Equipment / Patient Tie Downs
• Radio

44
Essential Communication with the Pilot
Discuss

• Air-ground radio communications
• Flight maneuvers
• (i.e. high G-force during take-off)
• Altitude restrictions (prior to taking on fuel)
• Cabin temperature considerations
• Weight of the patient (esp. if excessive)
• If electrical power available

45
Aeromedical Concerns

• Gas expands
• Hypoxia
• Stresses of flight
• Psychological status of patient escort
• Equipment
• Available
• Functioning
• Secured

46
Aeromedical Considerations of

• Eye and facial Injuries
• Head (free air?)
• Chest
• Respiratory
• Abdominal
• Anemia / Sickle cell

47
Aeromedical Considerations of

• Hypothermia and frostbite
• Psychiatric emergencies
• Maternal
• Pediatric
• Burns
• Amputations

48
Effects of Altitude on PaO2 may be Particularly
Hazardous for

• Shock
• Severe respiratory distress (ARDS, COPD)
• Decompensated cardiac disease (CHF, MI)
• Severe anemia (especially SS)
• Glaucoma, eye injury, recent eye surgery
• Cyanotic congenital heart disease
• Epilepsy
• CNS injury requiring 02

49
Things that will injure or kill the patient

• Illness
• Trauma
• Too much care
• Too little care

50
Matching the Escort to Patient

• Skill level of
• EMT I
• EMT II EMT III
• Paramedic
• Nurse
• Critical Care Air-ambulance
• Match escort to worst pt case scenario

51
You have a pt with a possible Ruptured Appendix
Who do you use?

• EMT I
• EMT II
• EMT III
• Paramedic
• Nurse
• Critical Care Air-ambulance

52
Other Medical Escort Patient Considerations

• Strength fitness
• Weight
• Motion sickness
• Pre-existing health problems
• Upper respiratory infections

53
Matching escort to patient

• Determine the potential problems
• escort could encounter should the
• patient deteriorate.....
• The escorts skill level and equipment should
  match the WORST possible patient problem.

54
Preflight Postflight check sheet essential
55
Potential Adverse Effects of Altitude on Escort

• Reduced attention span
• Impaired judgment
• Develop What, me worry? attitude
• Effects of drugs fatigue are potentiated
• Air sickness claustrophobia
• Decreased night vision, poor cabin lighting
• Increased insensible water loss due to
• decreased humidity

56
Stages of Flight

• Enplaning
• Dont step on plane door step while holding pt
• Take-off
• Secure yourself, pt, equipment
• Descent Deplaning
• Respect the pilots sterile zone
• Transfer of Care
• Give report. Label all equipment.

57
G loading for various patient positions
G force
A.
G force
B.
G force
C.
G force
D.
Aircraft Moving
Remember G force higher on takeoff
58
Safety Considerations

• Airstrip -- Airport
• Securing Equipment
• Securing Personnel
• Take-off and Landing
• Inflight Emergency
• Plane Helicopter

Safety
59
Safety Take-off Landing

• Artificial light should not be used. If need
  light--use a hand held flashlight with clear red
  filter.
• Respect the sterile field, do not talk to the
  pilot if below 10,000 feet. (This is a FAA
  regulation).
• Dont touch any cockpit controls unless the pilot
  instructs you to do so.

Safety
60
Safety Plane Helicopter Safety

• General
• Pilot is the final authority for continuing or
  canceling a flight.
• Helicopter specific
• Always secure loose items.
• Never hold IV poles or arms above your head.
• Stay lower than the person next to you.

Safety
61
Safety Securing Equipment and Personnel

• All equipment will be secured for flight (FAA
  Regulation 91.203
• All personnel must be secured for take-off and
  landing (FAA regulations 91.14, paragraph 3)

Safety
62
Safety Inflight Emergency

• Know the location operation of
• Exits
• Fire extinguishers
• Survival equipment
• Flotation devices
• Rapid Decompression procedure
• Secure patient, equipment yourself
• Stay calm do not disturb the pilot

Safety
63
Patient Problems in Flight

• Turbulence
• Positioning
• Lighting
• Motion Sickness
• Prolonged Immobility
• Disorientation
• Unable to ausc lung sounds

64
Other Patient Problems in Flight

• Exercise
• Oral Hygiene
• Sleep
• Elimination
• Ear Sinus Squeeze
• Tooth Squeeze

65
Electrical Power

• Do you have an in-plane power source?
• Carry extra batteries.
• Have equipment inspected on a routine basis.
• Remember There is a limit to the number
• of cords you can plug into an outlet.

Equipment Affected by Altitude
66
Oxygen

• To Calculate number of tanks Flight time
  plus two hours
• E cylinder lasts 1 hour at 10L/min
• Actual flow rate is greater than indicated
• Must be secured well

67
IVs

• Glass Bottles (Nitroglycerin bottles)
• Vent tape glass
• Dont hang above pts head
• Plastic
• Plastic preferred over glass when possible
• Use pressure bag
• Vent air prior to using pressure bag

Equipment Affected by Altitude
68
Cold Weather Considerations

• Ambu stiff plastic does NOT re-inflate well if
  it gets cold
• IV lines will freeze
• Patients head needs to be covered
• Battery life short
• Medical equipment batteries
• Plane batteries (Dont leave a light on!)
• Plastic may break (i.e. O2 rings)

69
Infection Control

• Universal precautions
• Cleaning equipment
• Cleaning aircraft / vehicle
• Discard of contaminated material

70
Seven Basic Survival Steps

• 1. Recognition
• 2. Inventory
• 3. Shelter
• 4. Water
• 5. Signals
• 6. Food
• 7. Survival / Spiritual activity

71
Most Common Reasons for Failure to Survive
Emergencies Are

• Wrong attitude
• Carelessness
• Lack of equipment
• Inability to use equipment
• Inability to adapt to environment
• No will to live

72
Safe Aeromedical patient care starts by educating
yourself and staff.Community Resources