Aeromedical pre hospital care

1
Aero-medical pre hospital care

• Jez Pinnell
• Consultant Anaesthetist Huddersfield Royal
  Infirmary
• YAS BASICS and Yorkshire Air Ambulance Doctor

2
Overview

• Advantages/disadvantages of helicopters
• Air ambulance services in UK
• Role of doctors on air ambulances
• CRM/safety
• Yorkshire Air Ambulance

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Whats so good about helicopters?

• Faster
• Smoother?
• Can go almost anywhere
• Skilled personnel to scene of incident over large
  distance

4
Whats not so good about helicopters

• Can pull over if problem
• Operates 24/7
• Any weather

• Limited access to patient (packaging vital)
• Noise and vibration
• Daylight hours
• Cant fly in fog/low cloud
• Flat unobstructed area to land
• Many hospitals have no HLS

5
UK model of pre hospital care

• Vast majority of emergency work undertaken by
  EMT/paramedics in road vehicles
• Trusts monitored by response times and not
  quality of care (although changing)
• With exception of Scotland all air ambulances are
  charities

6
Reforming emergency care

• Trend towards fewer EDs with concentration of
  specialist care e.g. coronary angiography
• Much longer transfer times if travelling by road
  and clearly a big impact on ambulance service
  trusts
• Will require greater use of air ambulance assets

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UK air ambulances

• Crews most often para/para
• May be from ambulance trusts or employed by
  charity
• London HEMS, Kent, Scotland currently employ
  doctors full time
• Most others have doctors working voluntarily for
  a variable amount of time

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Why have doctors on helicopters?

• Paramedics all senior and experienced
• Paramedics are able to give morphine
• Doctors waste time on scene
• P D Dissmann and S Le Clerc The experience of
  Teesside helicopter emergency services doctors
  do not prolong prehospital on-scene times Emerg
  Med J 2007 24 59-62
• Able to deviate from protocol eg hospital
  selection
• But not ketamine (yet!) or nerve blocks

9
Case report

• 20 yr old driver of car into van
• 3 dead on scene
• Driver extricated after 20 mins
• Compromised airway, massive flail chest, SaO2 70
  on O2, no radial pulse
• 3 doctors present
• RSI and bilateral thoracostomies (10 min)

10
Case report

• Immediate improvement, SaO2 to 92 and return of
  radial pulse
• 2 weeks in ICU
• On TV last month walking into court

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A and B on scene, C en route

• Definitive airway management RSI
• Definitive management of A and most life
  threatening B problems
• Garner A, Rashford S, Lee A, Bartolacci R.
  Addition of physicians to paramedic helicopter
  services decreases blunt trauma mortality. Aust N
  Z J Surg. 199969697701.
• Standards should be the same as in hospital RSI
• Combination of analgesia, anaesthesia and muscle
  relaxation for the intubation and afterwards on
  the way to the ED
• Technically difficult

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A and B on scene, C en route

• Thoracostomy is a well recognised procedure in
  the pre hospital setting
• Zane Perkins and Matthew Gunning
• Life-saving or life-threatening? Prehospital
  thoracostomy for thoracic trauma Emerg Med J
  2007 24 305-306.
• With or without a tube
• Same technique as described in ATLS

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Safety
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Safety

• Airfield safety
• PPE
• Fire training
• Methods of escape
• Correct stowage of kit
• Harness/doors
• Leaving/approaching aircraft

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Approaching aircraft
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CRM
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CRM

• CRM defined by CAA as a management system which
  makes optimum use of all available resources
  equipment, procedures and people to promote
  safety and enhance efficiency of flight
  operations
• Pre flight checks
• Morning brief (met, problems in area, safety
  card, medical)

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CRM

• Pre take off check
• Sterile cockpit
• Eyes and ears open
• Landing site selection
• Pre landing
• Landing

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Yorkshire Air Ambulance

• Charity
• Helicopter currently based at LBA
• Recently acquired 2nd aircraft to be based in
  south of region
• One pilot, two paramedics, doctor on ad hoc basis