Presentation of Scientific abstracts

;ClENTlFlC

ASSEMBLY, OCTOBER 6

RELIABILITY OF CLINICAL INDICATORS OF SUSPECTED TENSION PNEUMOTHORAX IN THE TRAUMA PATIENT Gail H. LaPlante, RN, ESN; Virginia M. Ribeiro, MD UMASS Life Flight, University of Massachusetts Medical Center, Worcester,

Mass.

Introduction. The purpose of this study was to determine if the clinical indicators (Cl) used to identify the presence of a tension pneumothorax (TP) are reliable as evidenced by documented improvement in patent status after needle decompression (ND). ND was performed for suspected TP with associated deterioration of vital signs or pulse oximo try, increased respiratory rate, jugular vein distention (JVD), tracheal deviation (TD), sub cutaneous air, sudden increased difficulty ventilating, absent or decreased breath sounds, or as part of resuscitation efforts, Methods. A 3-year retrospective chart review was done of all patients who had undergone ND by the flight nurse or flight physician before arriving at the receiving facility. Results. The study included 53 patients having at least one documented Cl of TP. Improvement after ND was noted in a total of 30%. None of these patients had documented TD or JVD, and only 16% had a documented air rush. Of the 16 who improved, the Cl noted were decreased breath sounds in 44%, decreased pulse oximeby in 19%, difficulty in ventilating with CPR in 13%, a resuscitation attempt in 13%, deteriorated vital signs in 6%, and the presence of subcutaneous air in 6%. Conclusion. The absence of JVD and TD does not exclude the presence of TP in trauma patients. More subtle clinical indicators may be more reliable in detecting TP.

USE OF THE LARYNGEAL MASK AIRWAY IN AIR MEDICAL TRANSPORT WHEN INTUBATION HAS FAILED Sharen Martin, RN, CFRN; Gage Ochsner, MD, FACS; William Agudelo, RN, CFRN; Frank Davis, MD, FACS LifeStar, Memorial Medical Center, Savannah, Ga. Introduction. This study will evaluate the effectiveness of airway management using the laryngeal mask airway (LMA) when intubation efforts have failed. Methods. Flight crew members were given a comprehensive training program on the LMA. A failed intubation was defined, and the crew members were given a data collection sheet to complete after LMA use. Documentation included failure of intubation, location, number of LMA insertion attempts, time required, Oz saturation, GCS, ISS, ABG, and history or radiologic evidence of aspiration. Results. From January 1996 through March 1997, 93% (14/15) of LMAs were successfully used as a means of airway control. Most LMAs were inserted in-flight, insertion time was fewer than 30 seconds, and no complications of vomiting or aspiration occurred. Mean ABGs obtained on arrival were Ph, 7.32; pCOz, 35; pop, 222; HCDa, 18.3; BE, -6.5; and O2 saturation, 95%. Conclusion. Progression through the algorithmic pathways of treatment come to a halt with the inability to obtain a patent airway. Our data show the LMA can be safely, rapidly, and effectively used for temporary airway control when more conventional methods have been unsuccessful.

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TRAUMA SCENE FLIGHTS AND HOSPtTAL DISCHARGE WITHIN 24 HOURS John Isfort, EMT-P: Julia F&z, RN; Steve English, RN; Portia Loveless University of Kentucky Aeromedical Program, Lexington, Ky. Introduction. The benefits of air medical transport are being questioned in this time of cost versus benefit maximization and the move toward managed health care. The purpose of this study was to identify patients discharged within 24 hours of admission after a scene flight and to evaluate patient parameters that may aid in the decision to transport by ground instead of air. Methods. A retrospective chart review of trauma patients transported from the scene to a .Level I trauma center from 1992 to 1995. Data collected were age, gender, Revised Trauma Score (RTS), Glasgow Coma Score (GCS), and Injury Severity Score (ISS). Results. During the 4-year period from January 1, 1992, to December 31, 1995, 4850 flights were conducted. In the 581 trauma scene flights, 53 patients (9.1%) were discharged from the hospital within 24 hours of admission. Mean totals were age, 30.6 years old; RTS, 11.54; GCS, 13.9 (SD 2.72); ISS, 4.37 (2.65). Forty-three men and 10 women were in the 24-hour discharge group. Conclusion. Of the trauma patients transported from the scene by this air medical service, 9.1% were discharged with 24 hours of admission. Patients presenting with near normal physiologic parameters at the scene could be evaluated further for other modes of transport. Future studies are needed to better define criteria that will assist EMS in de termining the best mode of transport for the trauma patient.

TWENTY-FOUR HOUR SHIFTSz PREPARED OR IMPAIRED? A PROSPECTIVE STUDY Christopher Manacci, RN; Kevin Rogers, RN: Gregg Martin, PhD; Betty Kovach, RN; Charlene Mancuso; William Fallon, MD Metro Life Flight, MetroHealth Medical Center, Cleveland, Ohio Introduction. The effect of duty shift length on performance is untested. In a prospective cohort model using repeated measures, we evaluated the effect of shift length on neuropsychologic performance indicators. Methods. Flight nurses were tested on memory, attention, reasoning, motor, and speed measures after both 24- and 12-hour shifts. Ratings of stress, fatigue, sleep quality, and logged amount of work and sleep were assessed. Data were analyzed by linear regression and repeated measures MANCOVA and MANOVA. Clinical significance was set at p r0.05. ResuL. One-hundred-forty-nine sessions on 16 subjects have been completed to date (85% of total sessions). Neuropsychologic test performance is not appreciably predicted by shift length, time of shim (day versus night), amount or quality of sleep before or during shift, or fatigue ratings. Age, gender, and education did not mediate shift length-test performance relationships. Uninterrupted sleep, stress ratings, and number of flights per shift modestly reduced some test scores. Predictably, repeated testings resulted in practice effects that reduced anafysis power. Conclurlon. Overall the independent variables do not predict neuropsychologic test performance (p= ns). Twenty-four-hour shifts per se do not result in cognitive decline when compared with lbhour shifts. Inconsistent sleep and the number and stress of flights per shift may have greater impact.

October-December

1997

16:4

Air Medlcal

Journal

TIME COMPARISONS USING HOT VERSUS CO10 LOADING ON A SCENE FLIGHT Diana Deimling, RN; Rose DeJarnette, RN: Carol Downing, RN; Renee Holleran, RN; Michael Rouse, RN; Steve Carleton, MD University Air Care, Cincinnati, Ohio

CORRELATION BETWEEN AN INlTlAL ATS OF ZERO AND PATIENT OUTCOME: POTENTIAL CRlTERlA FOR PRONOUNCING DEATH IN THE FIELD? Laura M. Criddle, MS, RN, CEN, CFRN, CCRN STARRight, Brackenridge Hospital, Austin, Texas

Intmductlon. The purpose of this study is to compare loading times, as well as total ground times, using both hot- and cold-loading methods on scene flights. Currently no data support the use of one loading method over the other as a significant time-saving technique. Hot loading does potentially expose the patient and persons involved to a variety of risks. Methods. The loading method used during scene flights was randomized according to the day of the month. Loading methods were timed from application of aircraft stretcher straps to liftoff. To detect a a-minute difference in loading times with an estimated 80% power at an alpha level of 0.05, a total of 104 flights will be needed to complete this study. An ANOVA will be used to evaluate these times, taking into consideration the indt vidual aircraft used. Results. Currently 18 flights have been entered. The mean cold-loading time for the 117 and 105 is 5.45 min. and 4.76 min., respectively. The mean hot-loading time for the 117 and 105 is 3.59 min. and 3.32 min., respectively. The total scene time means are as foC lows: cold loading the 117, 15 min.; cold loading the 105, 12.25 min.; hot loading the 117, 14.25 min; hot loading the 105, 10 min. Conclusion. Although no significant differences are being found @ = 0.67 for loading time and p = 0.80 for total scene time), the power is very poor with this small sample size. The estimated date of completion for this study is August 1997.

Intmductlon. Transportation of nonviable patients from the scene of injury wastes valuable resources, However, determining which patient will not survive is a diiicutt issue. Certain clear-cut criteria, such as rigor moms, lividity, decomposition, and decapitation, commonly are accepted as signs of field death. Dther criteria, such as massive head injury and asystOle, are accepted by some prehospital systems as indicators of death requiring no field care (e.g., CPR) and no patient transport. Still, these limited criteria result in the transporta tion of a significant number of nonviable patients, particularly trauma patients in whom perSistent Pulseless electrical activity, not asystole, is a common presenting rhythm. Because Revised Trauma Scores (RTS) are documented on all trauma patlents transported by the Austin EMS/STARFtight system, this study was designed to determine the ability of the RTS to predict the eventual outcome of patients whose initial field RTS was 0. Methods. Using the regional trauma center’s database to identify patients with an initial field RTS of 0, a B-year retrospective review (January 1994 to December 1996) was performed. A spreadsheet was developed to analyze patient age, mechanism of injury, condition at time of hospital discharge, site of transfer from the emergency department (ED), blood usage, and overall hospital charges. Results. A total of 39 patients wlth an initial RTS of 0 at the scene of injury were transported to the area’s only trauma center, where they consumed 173 inpatient days and 175 units of blood at a hospital cost of $992,499 during a as-month period. Df these patients, 62% had a blunt mechanism, 26% had penetrating trauma, and 13% suffered injuries of other etiologies (crush, hanging, electrocution). Thirty-three patients (85%) were adults, and 6 (15%) were younger than 15 years old. Twenty-six patients (67%) were pronounced dead in the ED, and 13 (33%) survived to OR or ICIJ admission. No pediatric patient left the ED alive. Only two patients (5%) survived to be discharged from the hospital, Patient A stayed 52 days and left severely disabled with a bill of $278,084. Patient B stayed 17 days and left in a vegetative state with total hospital charges of $100,102. Conclusion. If initial field RTS of 0 had been used as a criterion for “dead at the scene” pronouncement, only two severely disabled survivors would have been missed and almost a million dollars spent on futile care could have been saved in this a-year study.

USE OF BLOOD DURING AIR TRANSPORT IN TRAUMA PATIENTS

AIR MEDICAL TRANSPORT OF THE INJURED PATIENT: SCENE VERSUS REFERRING HOSPtTAL

C. Keith Stone, MD; Robert Herfel, MD; Jim Blake, MD Department of Emergency Medicine, University of Kentucky College of Medicine, Lexington, Ky. Introducllon. The purpose of this study was to determine the impact of blood given during air transport in trauma patients wtth a trauma score (TS) 5 12, the TS identified as the point of rapidly increasing mortality. Methods The trauma database was searched for all patients transported by air with TS < 12. Data collected included the use of blood during transport, TS, hematocrii (HCT), systolic blood pressure (SLIP) on arrival to the ED, and death rate (DTH). Patients receiving blood (BL) were compared with those not receiving blood (NBL) using Tukey-Kramer and chi-square tests with alpha set at 0.05 to determine statistical significance. Results. The database yielded 430 air-transported patients with a TS 5 12, including 51 BL patients and 379 NBL patients. No significant difference existed for TS (7.4 f 2.0 BL versus 8.0 * 2.1 NEL) and HCT (34.4 f 9.1 BL versus 36.0 ? 7.2 NBL). A significant difference occurred for SBP (108 t 40 BL versus 129 f 32 NBL) and DTH (47% BL versus 31% NBL). Conclurlon. The use of blood during air medical transport appears to have no significant impact on the outcome of trauma patients transported by air.

Alr

MedIcal

Journal

16:4

October-December

1997

Robert E. Falcone, Holly Herron, Howard Werman, Marco Bonta Columbus MedFlight, Columbus, Ohio Intmducllon. In a rural service area, do injured air medical patients transferred from the scene of injury differ from those transferred from a primary receiving hospital? Methods. Retrospective review of all injured patients transported by air to a single trauma center during calendar year 1996. Data collected include basic patient demographics, revised trauma score (RTS), injury severity score (ISS). probability of survival (PS), hospital length of stay (LOS), complications, disposition, and mortality. Results. Five-hundred-ninety-four of 1461 trauma admissions (40.7%) were transported by air: 363 from the scene (24.8%) and 231 from referring hospitals (15.8%). These two groups were similar in demographics, injury severity, LOS, and crude mortality: RTS = 6.61 versus 6.68 (p >0.05); ISS = 16.0 versus 16.0 (p >0.05); LOS = 6.9 days versus 7.3 days (p >0.05); mortality = 11.8% versus 10.8% @ >0.05). They differed significantly, however, in time from injury to definitive care (34.2 min. versus 196.2 min., p 0.5), 11.6% versus 44% @= 0.02.) Conclurlon. Patient groups were similar, suggesting similar triage criteria. Those transferred from a referring hospital took almost six times longer to reach definitive care and may have suffered an increased morbidity and mortality on this basis.

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I

BLOOD USAGE IN ROTOR-WING TRANSPORT

APPROPRIATENESS OF AIR MEDICAL SCENE RESPONSE Janet Orf, RN/MS; Tim Harrison, RN; Pam DeVellis, RN; Stephen H. Thomas, Suzanne Wedel, MD Boston MedFlight; Harvard Medical School: Boston University School of Medicine, Boston, Mass.

MD;

Introduction. Given the current atmosphere of cost containment, helicopter scene response is coming under increasing scrutiny. Appropriate prehospital provider triage to air medical EMS would be suggested by demonstrating equal injury acuity between scene and interfacility helicopter transports during a given period. This study compared injury acuity between air medical scene and interfacility transports. Methods. The study group comprised 6 months of air transports to an academic Level I trauma center with annual ED census of 65,000. All scene and interfacility trauma flights were analyzed to determine times of patient injury, flight crew arrival at patient, and Level I center arrival. Acuity characteristics of scene and interfacility patients were compared using t- and chi-square tests (p = .05 for all comparisons). Results. Interfacility and scene groups were similar with respect to revised trauma scores (means: scene, 10.7; interfacility, 10.4, p = .06) and injury severity scores (means: scene, 16.4; interfacility, 16.5, p= .91). Conclusion. Air-transported scene and interfacility patients’ similar acuity suggests ap propriate helicopter scene triage. Air-transported scene patients arrived at definitive care within about an hour of injury; interfacility transfers did not arrive at Level I care until 3.7 hours after injury.

Kathleen S. Berns, RN; Scott P. Zietlow, MD Mayo Medical Transport Service, Mayo Medical Center, Rochester, Minn Introduction. Blood transfusion for hemorrhagic shock is standard therapy. The purpose of this study is to document the development of protocols for administering packed red blood cells (PRBCs) and review the experience with in-flight blood transfusions. Methods. The rotor-wing registry was accessed during a 3-year period (August 1993 through August 1996) and 2131 records were reviewed to retrospectively analyze blood usage during transport Blood bank records and protocols were reviewed. Results. This hospital-based helicopter program maintains a cooler with 4 units of Onegative blood stored in the hangar and serviced by the blood bank. Blood was taken on all appropriate transports (91% interfacility, 9% scene), and 94 of 2131 patients (4%) were transfused. Criteria for blood transfusion included Hgb < IO, persistent hypotension following crystalloid resuscitation, and clinical signs of shock. Medical conditions con sisted of trauma, 48%; GI bleed, 25%; abdominal aortic aneurysm, 17%; other, 10%. The mean Hgb before and after transport was 8.9 and 10.2, respectively. Thirty-eight percent of the patients received an average of 3 units before transport Overall, 2 units PRBCs were given in-flight and another 12 units during hospitalization. No complications were encountered with blood transfusions. Conclusions. Selected rotor-wing patients will benefit from in-flight blood transfusions. Proximity of blood storage to the helicopter is mandatory to avoid delays in transport. A close working relationship with blood bank personnel ensures ready availability of current O-negative blood.

I STATE OF THE ART ASSEMBLY, OCTOBER 6 TRAUMA SCENE RESPONSE BY AN AUSTRALIAN PHYSICIAN-STAFFED HELICOPTER SERVICE Robert Bartolacci, Blair Munford, Anna Lee, Trish McDougall NRMA CareFlighbNSW Medical Retrieval Service, Westmead Hospital, Westmead (Sydney), Australia Introduction. The role of medically staffed helicopter services for scene response to trauma re mains controversial. All trauma scene responses from 1986 to 1994 by an Australian medically staffed helicopter emergency medical service (HEMS) have been analyzed retrospectively. Methods. Using modified TISS scoring, trauma cases cohort were assessed for interventions at scene before air medical team arrival and requirement for medical input. Using TISS scaring, air medical (AM) patients transported to one hospital were compared with a matched group of patients transported by ground paramedics (GP) for initial interventions required on admission. AM group survival was compared with MTOS cohort using TRISS method. Results. Of 445 scene patients, 270 were for potentially significant trauma (69 medical and 106 minor injuries). Trauma included spinal injuries (22.6%) isolated neurotrauma (7.0%) and multitrauma (70.4%). A total of 100 patients (37%) had head injuries. In 10.4% of patients, HEMS was first on scene, 58.2% had paramedics, 26.7% EMTs, and 4.7% others (RN/MD) were on scene before HEMS. Of the prior personnel group, 51.8% were well prepared, and 48.2% required HEMS input, multiple in 13.2%. Of note, more than 50% of patients with GCS <9 and paramedics on scene were not intubated before HEMS arrival. Twenty percent of patients were considered not to have benefited from physician presence, 35.9% received significant diagnostic input, and 44.1% received advanced medical procedures, multiple in 24.4%. These included RS 27%, blood transfusion 19%, and ICC 10%. Interventions required on admission to hospital were significantly reduced in the AM group compared with GP, as measured by TISS, and 1.43 times fewer early deaths occurred in the AM group. A highly significant (p c.002) 45% reduction occurred in predicted mortality in the AM group, with 9.6 fewer deaths than predicted per 100 patients transported (“W” statistic). Conclusion. Scene use of a physician-based team in an HEMS in Australia can significantly reduce predicted mortality of blunt trauma patients despite no reduction in prehospital times. This is likely to be a result of the enhanced procedural capabilities of senior critical care physicians compared with local alternatives. Presentation of this paper is supported by award of the ISAS Traveling Scholarship span sored by Helitech Pty Ltd and ISAS. A6

AIR AMBULANCE EXPERIENCE IN THE INDIAN SUBCONTINENT NPS Chawla, MD, FRCP, FACC; DK Chawla, MD East West Rescue, New Delhi ) In this presentation we review our most recent 150 missions. Various types of fixed-wing aircraft and helicopters are used. In India no dedicated air ambulance network exists. Currently the only manner to provide such is by use of private aircraft and helicopters that are modified for each mission. East West Rescue provides the equipment, physicians, and nurses for these missions. 1 Casualties are transferred from remote locations to bigger city hospitals for treatment and stabilization and then transferred home on a commercial carrier if required, At times casualties are transferred from an East West Rescue air ambulance to an air ambulance from another country for further management of patients in their home country. Many lives are saved and disabilities prevented by providing such a serwce even where dedicated air ambulances do not exist. Some of the problems prevalent in providing such a service in a developing country also will be reviewed. Trauma as a result of motor vehicle accidents is the most common cause. In the Indian subcontinent the time has come for a network of dedicated air ambulances.

October-December

1997

16:4

Air Medical

Journal

COMPARISON OF 61000 PRESSURE CONTROL IN PATIENTS TRANSPORTED WITH A DIAGNOSIS OF ACUTE AORTIC OISSECTION/ANEURYSM (AAO/AAA)

1 I

Leanne Perez, RN, MSN; Lowell Wise, RN, DNSc Stanford Health Services, Stanford, Calif.

J Bisciglia, C Binder, BJ Tortella, RF Lavery Section of Trauma and EMS, NJ Trauma Center, NorthSTAR Air Medical Program and the New Jersey Medical School

Introduction. Use of beta-blocker and vasodilatory drug therapy (treatment intervention) to urgently reduce blood pressure tn patients with AAD/AAA is well documented in the literature. A study was conducted to compare mean arterial pressure (MAP) control using this institutron’s aggressive blood pressure protocol with other transport programs. Methods. A 13-month retrospective revrew of all AAD/AAA transport records was conducted. Seventy patient records transported by this institution’s team and 70 transported by all other agencies to this institution were reviewed. Statistical analysis compared the groups’ performance on two outcomes: frequency of treatment intervention on uncontrolled MAP and frequency of hospital arrival with MAP control. Results. Significantly more patients transported by this institution received treatment intervention for uncontrolled MAP and arrived with MAP control between 60 and 80 mm Hg. Conclusion. This study demonstrates the efficacy of an aggressive MAP control protocol in caring for patients with AADIAAA.

USE OF RESTRAINTS IN AIR MEDICAL TRANSPORT

THINK BEFORE YOU ACT: A NATIONAL SURVEY OF INTERHOSPITAL TRANSFER POLICIES AND PRACTICES

Introduction. As health care evolves, air medical program (AMP) interhospital transfers will come under increasing scrutiny. The objective of this study was to evaluate various components of interhospital transfer policies of AMPS across the country. Methods. A structured telephone interview of the chief flight nurse (CFN) or administrator of 90 geographically selected AMPS conducted by a single interviewer, who was nonmedically trained and used a scripted questionnaire. Results. Seventy-seven (86%) AMPS contacted agreed to answer the questionnaire. CFN or administrator unavailability was the reason for nonresponse. Mean number of flights performed per year was 1046 divided between 29% scene and 71% interhospital transfer. Mission profile included fixed wing (19, 25%) rotor wing (45, 58%) and both (13, 17%). Thirty-five (45%) respondents require prior administrative approval and 24 (31%) require prior medical approval before accepting an interhospital mission. This policy was most often for financial approval or long-distance transport. Ninety-four percent of respondents transferred patients to facilities other than AMP host hospital; 30% require medical authorization, 35% administrative authorization, and 35% decide on financial, distance, and contract hospital considerations. Conclusion. This survey indicates that most AMPS use some form of screening mechanisms for interhospital flight requests. With managed care causing all health delivery systems to examine the most efficient use of resources, AMPS can continue to stay ahead of trends that impact our industry.

I

FAMILY MEMBER RIDE-ALONGS DURING INTERFACILITY TRANSPORT

Kirk Brauer, MD; Kevin Hutton, MD University of California-San Diego

Jackie Brown, RN; Robert Donovan, MD: Eric Chaney, EMT-P Air Med Team, Doctors Medical Center, Modesto, Calif.

Although the practice of restraining violent and agitated patients is quite commonplace, such restraint is not uniform and has not been scrutinized in the air medical transport environment. The objective of thus study is to identify and characterize the use of physical and chemical restraining methods in the air medical and critical care transport setting. A retrospective survey study by faxed questionnaire to 92 medical directors who are members of the Air Medical Physician Association was performed. Neither program size nor program type was found to correlate with the use of particular restraint. Cloth was the most common physical restraint (73%); both benzodiazepines and paralyhcs were the most common chemical restraints (53%). Injury to crew members was not widespread. This study of air transport services reported a lower prevalence of injury to personnel (17%) than is reported in studies from emergency departments (67%). Furthermore, air transport services are more likely to possess protocols governing actions toward violent patients (65%) than are emergency departments, as has been reported in the literature (50%). Protocols varied in nature and extent. An institution and implementation of consensus protocols should be sought with focused data acquisition to standardize the education of personnel in managing the problem of violent patients.

Introduction. In an effort to help meet the psychosocial needs of our patients and their families, AMT developed a Ride-Along program. Our Ride-Along policy and procedure identifies the individuals who may accompany a patient and the circumstances under which this may occur. The purpose of this study was to evaluate our Ride-Along program from the family members’ perspective. Methods. A telephone survey of family members who accompanied patients during a transport was conducted. The survey contained questions designed to evaluate the bene fit to patients and their family members and the operational and safety components of the Ride-Along program. Results. Of 883 AMT transports, 60 (7%) had family member ride-alongs. Thirty-one (52%) of these family member ride-alongs were surveyed. More than 95% of family member ride-alongs believed it was beneficial for them to accompany patients on transport. They also believed they were able to provide valuable information (i.e., medical history, signing of consents) to receiving physicians that would not have been available immediately had they not accompanied the patient on transport. All surveyed believed they recerved an adequate safety briefing in preparation for the flight. However 3 (10%) stated they felt uncomfortable during the transport. These individuals commented they were afraid of flying but had gone on the transport because the circumstances warranted it. Conclusion. Allowing family members to accompany patients during transport is beneficial and can be done safely without compromising patient care.

Air Medical

Journal

16:4

October-December

1997

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1

SUBSTANCEABUSEPOLlClESOFHELlCOPTEREMERGENCYMEDlCALSERVICES (HEMS)INTtlEUNlTEDSTATES

BJ Tortella, RF Lavery, ES Danielson Section of Trauma and EMS, NJ Trauma Center, NorthSTAR Air Medical Program and the , New Jersey Medical School Introducllon. The purpose of this study was to collect data on HEMS substance abuse policies. Methods. A survey was sent to the chief flight nurses of 272 HEMS programs across the United States. A single follow-up letter was sent to nonrespondents. The survey requested program characteristics and data on drug screening, action taken for positive tests, and treatment payment mechanisms, Asrulls. One-hundred-thirty-eight (51%) surveys were returned. Programs flew a mean of 898 missions and were divided among fixed wing, 29 (21%); rotor wing, 76 (55%); and both, 33 (24%). Eighty-five (62%) programs perform preemployment drug screen ing, 91 (66%) screen for “triggering events,” and 35 (25%) screen routinely. Thirty (22%) programs give employees paid leave after testing positive, 32 (23%) give unpaid leave, and 26 (19%) discharge the employee. Thirty-two (23%) programs pay for sub stance abuse treatment, 70 (51%) require the employee/employee insurance to pay, and both the program and employee pays in 9 (7%) programs. Conclusion. Management imperatives, such as risk avoidance and public expectation of a nonimpaired workforce, demand zero tolerance, but the nature of HEMS as a helping profession obligates the support of fellow employees. However, one third of HEMS have zero-tolerance policies. Further, employees and/or their insurance carrier pay for rehabilii tation at half of HEMS that offer a second chance. Balance needs to exist between eco nomic and perceptual concerns and the well-being of HEMS providers.

AIAMEDICALPROGRAMMERGERANDSTRESS Holly Herron, Barbara Dean, Robert E. Falcone Columbus MedFllght, Columbus, Ohio Introducllon. How does the stress of merger affect job stress in air medical transport? Methods. An anonymous survey of 104 transport personnel in a Midwestern critical care transport program with merged air (2 years) and ground (6 months) components. Tools included the Social Readjustment Rating Scale (SRRS), which quantitates stressful life events on a weighted scale that allows summation as a score (150 to 199, mild stress; 200 to 299, moderate stress; > 299, high stress), and the Medical Personnel Stress Survey (MPSS), which quantfhates work stress in four categories: organizational stress (OS) related to the work environment; frustration/exhaustion (FE) related to patient care: job satisfaction (JS) related to decreased self-worth; psychosomatic complaints (PC) manifested as personal illness. Statistical anafysis was performed with a variety of tools. Resulls. Fifty of 104 personnel responded completely (46%). Average SRRS was law at 130.9 * 62.1; only 20% had scores higher than 200. No signfficant differences existed in MPSS in personnel with high and low SRRS scores. Additionally, the SRRS correlated only weekly with OS (r = -0.297, p t0.05). Wiiin the MPSS, OS correlated with FE and JS (r = 0.493, p = 0.0005; r = -0.593, p t0.0001) and FE correlated with JS (r = -0.36, p = 0.01). Conclusion. The overall personnel stress levels in this air medical transport program with merged air and ground components are low and appear to be unrelated to OS. It may be possible to target stress reduction programs to specific individuals and areas of concern.

INNOVATIONS C Corriere, C Zarro, RF Lavery, BJ Tottella Section of Trauma and EMS, NJ Trauma Center, NorthSTAR Air Medical Program and the New Jersey Medical School Intmductlon. Caring for an infectious patlent In the air medical environment presents a special challenge to all air crew members (ACMs) Involved. The purpose of this study was to gather data on the infectious disease control practices of AAMS air medical pro grams (AMPS). Melhods. A structured telephone survey of chief flight nurses (CFNs) of 151 geographff tally selected AMPS by a single nonbiased medical student from July to August 1996. Results. One-hundred-thirty-eight (91%) nurses answered the survey, and no program refused to participate (13 CFNs were unavailable). Mission profile was 32% scene and 68% interhospiil with an average of 950 patient transports per year. Transport type was 61% rotor wing, 17% flxed wing, and 22% both. Flight physicals for ACMs were required by 57% of the AMPS. Respondents reported preemployment screening for rubella, tuberculosis, and varlcella. Interestingly, 17% of the AMPS in this survey reported preemploymerit HIV testing. Immunization was mandated by 57% of AMPS, including HVB, measles, rubella, and tetanus. Nine percent refused transport because of specific contagious condition (tuberculosis prlmarily). A formal decontamination policy was in effect by 88% of the AMPS. Seventy percent of AMPS wear OSHA-approved filter masks: 97% require reporting pathogen exposure for ACMs. Conclusion. A current, well-informed infection control program, continuing education, and 100% compliance with universal precautions will assist in reducing an accidental exposure. These behavioral strategies to reduce transmission also can be extended during training sessions to the prehospftal and hospital personnel whom the air medlcal prc-

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& EXPERIENCE ASSEMBLY,

OCTOBER 6

THECARDlACPATlENTtFROMTRANSPORTTDMMlSSl0NANDBEYOND Wanda Llddell, ARNP, PM: Paula Davis, RN, PM ShandsCair Flight Program/Emergency Department, Shands Hospital at the University of Florida, Gainesville, Ffa. Intmducllon. A muitldisciplinary pathway was developed in an attempt to provide stateof-the-art patient care while complying with hospital-wide cost-containment goals, Methods. A multidisciplinary team with representatives from cardiology, emergency medicine, nursing, transport, home care, etc. was put together to develop universal guidelines for the care of the “routine” acute myocardlal infarction (AMI) patient. This team developed guidelines based on the most updated recommendations in the lfferature. When entering the system through prehospiil intervention from the flight team, the ED, or through a prescheduled admission, the chest pain patlent is evaluated for AMI, as well as to determine appropriateness of the pathway for each patlent. Raul~. Within the first 2 months, patients with the diagnosis of AMI who were started on the AMI crftical pathway had a 50% decrease In hospitalization cost compared with prepath costs. This decrease occurred through a decreased length of stay and a reduo tion In the number and/or frequency of procedures and tests performed. When following a pathway based on the most updated recommendations, quality care leads to overall im provement In patient outcomes. Conclurlon. By following a standardized guideline based on updated data, patients re ceive the “best” care from the start. When a patient’s condition warrants them, deviations from the path may be made. Even in cases in which the patient has “fallen off the path,” cost savings to the hospital and the patlent are found. I

October-December

1997

16:4

Alr MedIcalJournal

THE BENEFIT AND PRESENCE OF TRANSPORT TRIAGE SYSTEMS

THE HOT-LOADED PATlENT: REVIEW AND ANALYSIS OF ONE YEAR’S EXPERIENCE

Gary J. Stromberg, RN, CEN Careflight, St, Joseph Hospital, Lexington, Ky,

Laura M. Criddle, MS, RN, CEN, URN, CCRN STARFlight, Brackenridge Hospital, Austin, Texas

Intmductlon. As managed care environments continue to pressure transport services to better use and manage their resources, it has become necessary to develop systems for this use, Currently the presence or the benefit of these systems is unclear; hence, the purpose of this study. Methods. Data were gathered using a questionnaire that was completed by the program managers of 57 critical care transport services. Results. Df the 57 respondents, only 25 programs (43%) currently use a transport triage system. Of those 25 programs, 17 (66%) have experienced more appropriate use of transport resources. Although use improved, only three programs (12%) stated increased reimbursement rates. In these systems, only four programs (16%) allowed the duty staff to participate in the transport mode decision-making process. Conclutlan. Because the evolution of managed care seems unavoidable, it is necessary for transport programs to better use their resources in a cost-effective manner. Although haff the programs currently use a triage system, few have experienced reimbursement improvement. Hence, all programs apparently must begin to use and develop a unified transport triage system to improve appropriateness and subsequent reimbursement by our nation’s major health care payers.

Introduction. Hot loading (placing patients in the helicopter without shutting it down) is a common practice among rotor-wing programs that respond to scene calls. Although thought to speed turnaround time, this practice has several drawbacks, Problems include noise, which makes patient report and assessment difficult; increased flying debris: risk of serious injury to ground personnel; and a general rise in the “confusion factor.” The purpose of this study was to analyze the frequency, ground time, and short-term outcomes (disposition from the emergency department) of hot-loaded patients transpolted by the STARFlight program. Methods. This descriptive study consisted of a l-year introspective review of night logs to identify all hot-loaded patients. Only calls with actual patient transports were included. Hot loads performed for mechanical reasons also were excluded. Resuhs were analyzed by nature of the call (trauma versus medical), number of patients (single versus multi! ple), and type of aircraft (Bell 412 or Bell 206). Results. In 1996 STARLFlight transported 1164 patients from the scene of illness or injury: 246 (21%) were hot loaded. Overall, the mean hot load ground time was 7.0 min. (median, 6 min.; mode, 5 min.). The shortest turnaround times were for single trauma patients (6.6 min.). Medicine patients averaged 7.3 min., and mean ground time was 10.3 min. whenever multiple patients were transported. Patients flown in the Bell 412 had average scene times of 6.9 min., whereas those transported in the smaller Bell 206 required a mean of 7.4 min. Conclusion. Hot-loaded patients were generally not critically ill or injured: 69% were stable enough to be discharged from the ED or admitted to a nonmonitored bed. Hot loading rarely is accomplished in less than the time required to shut down and restart the helicopter. Shut-down/start-up times for the 412 and the 206 are 2 to 3 min. and 4 to 5 min., respectively. Ninety-five percent of all hot loads required 3 or more minutes. Multiple patient hot loads always exceeded helicopter shut-down/start-up times. Both medicine (nontrauma) and Bell 206 transports consistently required longer ground times.

PEDIATRIC PEDESTRIAN VERSUS MOTOR VEHICLE PATTERNS OF INJURY: DEBUNKING THE “MYTH”

-r THE INTEGRATlON OF CRITICAL THINKING INTO THE ADVANCED CLINICAL SKILLS LASORATORY FOR THE AIR MEDICAL TRANSPORT TEAM

Kathy Haley, Sharon Hammond, Randy Orsborn, Robert E. Falcone Columbus MedFlight and Children’s Hospital, Columbus, Ohio

Paula Davis, RN, PM; Wanda Liddell, ARNP, PM ShandsCair, Shands Hospital at the University of Florida, Gainesville, Fla.

Introduction. Mechanism of injury has been widely used to enhance the ability of EMS providers to recognize predictable injury patterns. One such pattern, referred to as “Waddell’s triad,” identifies a trio of Injuries associated with pedestrian motor vehicle collision (MVC), including trauma to the head, abdomen, and lower extremities. We ques tioned this as a common injury pattern for this mechanism. Methods. A retrospective chart review of 4444 pediatric trauma patients admitted to a regional pediatric trauma center between 1992 and 1996. The source of this information was the medical center’s trauma registry. Results. The study included 465 patients in the registry who suffered a pedestrian MVC; 226 of these suffered isolated head injury, and 78 patients experienced a combination of head and leg injury. Only 11 patients suffered the predicted “triad” of head, leg, and ab dominal injury as a resuft of pedestrian MVCs (2.4%). Two of these children suffered only minor head injury, and all 11 survived. Conclurlon. Although the concept of Waddell’s triad is theoretically valid and a high index of suspicion should be maintained, the incidence of this predictable injury pattern is low. Educational emphasis should be placed on other aspects of mechanism of pedestrian injury.

Introduction. Including criiical thinking into skills laboratories raises the level of complexity to greater heights, Methods. Air medical skills laboratories traditionally have focused on the mechanical ability of the team to perform advanced life-saving techniques, including but not limited to intubation, cricothyrotomy, chest tube placement, and central line insertion. With practice, these skills became simple to perform in the laboratory setting. Integrating this laboratory with patient scenarios that involve a multitude of obstacles elevated staff participation to a new level. With this change, getting the tube in was no longer enough. Now all team members had to participate with their full concentration to accurately assess each situation and treat each appropriately. Retultr. Each two-person RN/PM team was given two scenarios in which complicated medical and trauma patients were involved. Multiple systems were involved with each patient scenario. Each situation required multiple advanced clinical skills to validate ongoing clinical competency, as well as required the RN and PM to work together as a team to fully address all the patients’ problems during stabilization and transport. At the conclusion of each scenario, the medical director and the education coordinator gave imme diate feedback to each team. Opportunities for improvement were identified, and this lab oratory was integrated into the ongoing quality assurance program. Conclusion. Including critical thinking into clinical skills laboratories will improve flight teams’ performance by preparing them to think beyond the technical skills that prevlously have taken precedence on many flights.

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AAMS APPROPRIATE CRITERIA REVISITED Robert J. O’Malley, RN, MS Trauma Program, Patient Care Services, University of California-Davis Sacramento, Calif.

LEGAL ISSUES: MEDICATION TRANSPORT ACROSS UNITED STATES BORDERS Medical Center,

Mary A. Svoboda, RN; Dan J. Mueller, RN; David W. Claypool, MD; Ann Decker, JD Mayo Medical Transport Services, Mayo Medical Center, Rochester, Minn.

Introduction. Our fixed-wing program transports patrents into and out of the United Introduction. In 1990, the AAMS position paper on criteria for the appropriate use for States. On these flights, our medical team carries narcotics and other prescriptive medair medical transport was published; a list version was published in a separate report in ications, as well as documentation (medical control letter) from our DEA-registered 1994. The experience of nine programs was presented at the 1996 Air Medical physician director detailing that these medications are under his directed use. A vigorous Transport Conference. challenge by Customs on reentering the United States after patient transport led to furMethods. Based on the programs’ experience and criteria analysis, an alternate list is ther examination of our compliance with federal regulations concerning medication imoffered that is intended to increase the precision of the criteria and remove duplication port/export. This paper describes our findings and changes in our operation. and ambiguity. Methods. Contacts were made to other regional services, as well as services with a naI tronal ‘, Examples: reputation in international transports, along with the AAMS authority. Contacts Previous: Experienced, or had great potential to experience, injury to the spinal cord, wrth our legal department and later a specialized legal firm to federal authorities resulted spinal column, or neurologic deficit in numerous referrals (Customs, FDA, DEA). Suggested change: Paralysis, parathesia, or focal neurologic signs : Results. These results are not legal advrce. Our medical control letter was said to be irPrevious: Acute myocardial infarction that requires therapy or diagnostic procedures not relevant. Violations of medication import/export laws may include fines up to $25,000 available at the referring hospital and 15 years imprisonment per count! Exemptions for individual international missions Suggested change: Acute myocardial infarction transferred for emergent angiography, require several weeks to obtain and therefore do not meet our needs, Addressing these thrombolysis, or angioplasty issues has taken well more than a year. Legal negotiation with the DEA has resulted in Previous: High-risk obstetric condition our obtaining an exemption from import/export registration requirements. Currently a Suggested change: Preterm labor, preeclampsia, eclampsra, toxemia, or fetal distress notarized copy of this exemption accompanies all international flights. This information transferred to tertiary center pertains only to U.S. regulations. Obtaining and complying with the regulations of other Conclusion. Industry-wide criteria foster appropriate use and promote communication nations seems almost impossible. regarding air medical transport Conclusion. All services transporting internationally should consider themselves vulnerable to rigorous enforcement action at U.S. and other national borders. Individual program policies and industry/AAMS guidelines need to be established.

ROTOR-WING TRANSPORT OF A PATIENT WITH A BIVENTRICULAR DEVICE: CHALLENGING NEW FRONTIERS OF TRANSPORT Carleen Kelley, RN, MS, CCRN; Brendan R. Furlong, MD: Ann McKee, RN, BSN, CCRN; Steven W. Boyce, MD: Kathleen W. McNichols, MD MedSTAR Transport Services, Washington Hospital Center, Washington, DC

STANDARD ANNUAL RECURRENT TRAINING Jane S. Wynn, RN Air Medical Alliance, Dallas, Texas

Introduction. The accepted standard in the industry for survival/safety training is annual recurrent educational programs. The industry has never looked at nor tested content Introduction. We present the interhospital transfer of a patient with an open chest and a comprehension or retention of this subject. We decided to do a sample testing of crews’ biventricular assist device, the ABOMED BVS 5000, as an example of the clinical ad- 1 ability to understand and retain survival training material. Methods. This study solicited the participation of four program crews that had previous vances in helicopter transport. Implantation of mechanical circulatory assist devices has become an established method for treatment of patients in severe cardiogenic shock and training in safety and survival. A test on safety and survival training content was adminisas a bridge to cardiac transplantation. An increasing number of these patients needs to tered to nurses and paramedics before a refresher course (Test 1) and immediately after the course (Test 2); the same crews took the test 6 months later (Test 3). Ninety-six crew be transported to regional centers of cardiac excellence. members took Tests 1 and 2, whereas 79 (82%) took Test 3. Methods. Through the process of preflight planning, in-flight adaptation, and postflight debriefing, we have developed innovative strategies to affect the transport of highly comResults. The average time since a survival course had been attended by any one of the plex cardiac patients. Specific considerations include the helicopter, equipment, and crew ~ crew members participating in this study was 1 to Y/Z years. Pretraining Test 1 mean test score was 60 (60%); the posttraining Test 2 average score was 92 (92%). composition and training. Results. The ideal helicopter allows the stretcher to remain in a secure elevated position, However the B-month Test 3 score mean was 65 (65%). Conclusion. Flight crews do not retain a safe level of survival skill knowledge with annual complete access to the patient, and adequate space for the ABOMED BVS 5000 console with consideration for emergency manual pumping. Specialized equipment includes the recurrent training. Therefore the industry needs to reevaluate its position on standard anABOMED BVS 5000 console, brackets, and critical care monitors. These must be secure, nual recurrent training. Survival training is too important for flight crews to train only visible, and electrically compatible. The flight crew should have three clinical providers. once per year. Rescuer care is as important as pabent care! Staff training should include an ABOMED BVS 5000 certification course, a clinical practicum, and a mock transport practicum. Conclusion. By determining the helicopter type and configuration, selecting specialized equipment, and educating the flight crew, we provide the basic template for planning future complex transports.

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POSTER SESSION, OCTOBER 6 INTERVENTIONS MADE TO IMPROVE NONPERMANENT MEDICAL CREW MEMBERS’ KNOWLEDGE OF SAFETY AND EMERGENCY PROCEDURES JoAnn Newcomb, RN, BSN UMASS Life Flight, University of Massachusetts

/ I

AMBIENT (NOISE MEASUREMENT MADE IN AN) AIR MEDICAL TRANSPORT HELICOPTER

William E O’Brien,’ MICP; Patricia E. Connelly,* PhD, CCC-A, FAAA Carl J. Corriere,’ RN, I MSN,.’ Bartholomew J. Tortella,a MTS, MD, FACS Departments of Emergency Medical Services’ and Surgery,2 UMDNJ-New Jersey Introduction. To increase nonpermanent medical crew members’ knowledge of aircraft Medrcal School, Newark, NJ safety and emergency procedures, briefings were instituted for all crew members. During Introduction. The issue of patient safety with regard to the harmful effects of excessive a 3-year period variations of the briefings were tried and therr efficacy evaluated. Methods. Crews were taught and tested on procedures for emergency landings, ditching noise exposure during air medical transport has not been systematically investigated. in water, aircraft fires, use of emergency locator transmitter, and use of survival kit. A This study was the inibal phase of a multitiered investigation designed to compare air multiple-choice test was given to evaluate what was learned and retained. medical helicopter norse measurements made conventionally with those made through advanced technologies borrowed from audiology and hearing science. Results Table 1 Average number of correct answers to 16 questions ’ Methods. Ambtent noise was measured In a Sikorsky S-76B helicopter configured for air medical transport using a Bruel & Kjaer model 2203 precision sound level meter with a ~. -~ Type 1616 external one-third octave filter set. Three trials of measurements using the A and C scales and at octave filter settings of 80, 100, 200, 400, 800, lk, Zk, 2.5k, 3.15k, Permanent crew -.members 14.7 (92%) 15.4 (96%) and 4k Hz were made during cruisrng. Nonpermanent crew members i 11.7.(73%) 1 11 .l (69%) 12.1 (75%) 12.2 (764 Results. Results of a two-way ANOVA revealed a statistically signiftcant effect for Octave Conclusion. Despite multiple interventions, we were unable to increase the scores of Band Measured (Hz) (F(11,144) = 341.1, p c.05). In addition, no statistically significant nonpermanent medical crew members. Flight programs using nonpermanent medical effect exists for Trial (F(2,144) = 0.005, p >.05), nor one for the Trial x Octave interactron crew members should be aware these staff members may require extra attention, partic(F(22,144) = 0.73, ,n>.O5). ularly in regard to safety in the aircraft and procedures in the event of aircraft emergency. Conclusion. Ambient noise In the Sikorsky S-76B helicopter is extremely stable as measured during the cruising porhon of flight. The dB-C scale yielded the highest mean level ~ (103.7 dB), and the highest mean level for the octave bands was at 800 Hz (95.6 dB). i These data provide a solid base of comparison for the data measured during the second tier of this investigation using other advanced technologies. Medical Center, Worcester,

Mass.

THE IN-FLIGHT PROFICIENCY CHECKRIDE: “GO AHEAD, MAKE MY DAY!” MSG Thomas W. Stark, Ill; Col. Carl A. Merwin 514th Aeromedical Evacuation Squadron, Air Force Reserve Introduction Background. Mrssion overview, basic air crew compliment Medical Air Crew Flight Evaluation. Who, what is covered, when, where, why, and how often The Sample Checkride (see handout AF form 3862) a. Emergency procedures (EPE): fuselage fire, crash landing, ditching, and emergency signals b. Emergency equipment: fire extinguishers, escape ropes/ladders, exits/chopping location, and emergency lights c. Aircraft systems: oxygen, electrical, and lighting systems d. Nursing considerations: develop care plan/stresses of flight, combat wound manage ment, IV therapy, cardiac/respiratory arrest, and medical equipment e. Stresses of flight: decreased partial pressure of oxygen, decreased humidity, noise, vibration, and G-forces Closing remarks and questions and answers

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ATTITUDES REGARDING FAMILY MEMBERS ACCOMPANYING PATIENTS IN FLIGHT: ONE FLIGHT PROGRAM’S PERSPECTIVE Margaret M. Naughton, RN; Cheryl A. Coyle, RN, BSN UMASS Life Flight, University of Massachusetts Medical Center, Worcester, Mass, Introduction. Occasionally requests have been made to transport famrly members with patients during flight. We proposed to study flight crew bias and implications of transporting family members in an air medical program. Methods. A lo-question, multiple-choice survey was developed and completed by flight physicians, attendings, residents, flight nurses, and pilots. Forty-seven surveys were completed. Results. All pilots and flight nurses, most attending& and some residents have flown with a family member accompanying a patient. All crew members believed emobonal comfort definitely increased for the patient; however, this comfort did not necessarily benefit overall patient care. Conclusion. Transport of family members may not significantly benefit overall patient care. However, a positive emotional component exists that needs to be considered in determining whether a family member will accompany the patient.

All

RETENTION OF KNOWLEDGE OF SAFETY AND EMERGENCY PROCEDURE8: A COMPARISON BETWEEN PERMANENT AND NONPERMANENT MEDICAL CREW MEMBERS JoAnn Newcomb, RN, BSN UMASS Life Flight, University of Massachusetts

Medical Center, Worcester, Mass.

Inlroducllon. UMASS Life Flight air medical transport program has a medical crew of nurse and physician. Ten permanent flight nurses average 131 flights per year and participate with pilots in daily and postflight briefings and other discussions about safety issues. Flight physicians are residents in their second or third year of emergency medical training who rotate shifts as nonpermanent medical crew members during a Z-year period and do not participate in many nonflight, safety-related activities. Twenty-five flight physicians average 30 flights per year. We investigated whether all crew members are equally prepared to respond in the event of an aircraft emergency. Method. A written test consisting of 16 multiple-choice questions was given to all medical crew members. Ouestions covered procedures for emergency landings, ditching in water, fire on board aircraft, use of emergency locator transmitter, use of survival kit, and other topics. Results. Nine flight nurses answered an average of 15.2 of 16 questions correctly (95%). Twenty-five flight physicians answered an average of 10.1 of 16 questions correctly (63%). Conclusion. Nonpermanent medical crew members may be less prepared to respond in the event of an aircraft emergency than permanent medical crew members.

AN EVALUATlON OF TtlE NURSING INTERVENTION CLASSIFICATION FOR AIR TRANSPORT DOCUMENTATlON Sally Hsiao-Li Wu, RN, MS; Cheryl Bagley Thompson, EdD; Stephen C. Hartsell, MD University of Utah, Salt Lake City, Utah

RN, PhD; Linda L. Lange, RN,

Introducllon. The Nursing intervention Classification (NIC) is a standardized classification of nursing interventions and is one of the taxonomies contained in the National Library of Medicine’s Metathesaurus for the Unified Medical Language System. Because flight nurses implement many interventions beyond the traditional scope of nursing pramtice, the NIC may not be appropriate for use by flight nurses. The study purpose was to examine the utility of the NIC for air transport documentation. Method. The study used a retrospective, descriptive design. Data were collected from 20 charts for cardiac patients older than 16 years who were transported by rotor-wing aircraft, Data elements were identified and analyzed for presence in the NIC. Results. Within the 20 charts, 724 nursing interventions were found: 711 were present in the NIC. However, many of the interventions were done on a more independent level than indicated by the NIC. The interventions were found most frequently within the Physiological: Complex domain of the NIC. Conclusion. Minor modifications of the NIC will be needed if the NIC is to serve as a standardized language for air transport documentation or a computerized patient record. Fundlng. The Foundation for Aeromedical Research

Al2

DISCREPANCIES FOUND BY AIR MEDICAL PERSONNEL DURING INTERHOSPlTAL TRANSFERS THAT DELAY PATlENT TRANSFER AND/OR POTENTIALLY AFFECT PATIENT OUTCOME Ed San Miguel, MD; Fred Severyn, MD, FACEP St. Vincent Mercy Medical Center, Dept. of Emergency Medicine, Residency Program, Toledo, Ohio Introducllon. Life Flight crews report that in a significant number of flights, their down time at community hospitals is increased because of a discrepancy in what is perceived as minimally required interventions before transport. The purpose of this study is to better tailor the outreach program lecture series based on the collected data. Methods. A descriptive chart review of all air medical interhospital transfers from March 1 to October 31,1996. Rsrulk A total of 925 flights was evaluated. The incidence of interventions before air transport were immobilization, 42 (4.5%); airway, 95 (10.3%); IV access, 13 (1.4%); and chest decompression, 43 (4.6%). The confidence intervals were immobilization (3 to 6%) airway (6 to 12%) IV access (0.6 to 2%) and chest decompression (3 to 6%). All interventions were made pretransport. Conclusion. More than 10% of patients required airway management. This significant finding is a top priority to emergency medicine specialists, Immobilization and chest de compression were close in their percentages, reflecting a serious need for better educe tion and training for those involved in the initial care of the sick and injured before air medical transport,

LARGE-SCALE VOCABULARY TEST OF AIR TRANSPORT DOCUMENTATlON Cheryl Bagley Thompson, RN, PhD; Cheryl Strong, RN, BSN University of Utah College of Nursing, Sait Lake City, Utah Introducllon. The National Library of Medicine (NLM) is evaluating the Unified Medical Language System (UMLS) for applicability as taxonomy for documentation of patient care. This portion of the study was designed to determine if the terms found within patient records for air transport are contained within the UMLS thesaurus. Method. The study used a retrospective, descriptive design. From a mutticentered sam ple of air transport records, 1117 terms were selected and evaluated using a World Wide Web-based interactive tool developed by the NLM. Results. An exact match was found within the UMLS thesaurus for 642 (57.5%) of the terms. Three-hundred-sixty seven (32.9%) of the terms were either synonyms, associated with, broader than, or more specific than comparable terms found within the thesaurus, A comparable term was not found wfthin the thesaurus for only 108 (9.7%) terms. Conclurlon. A clinical vocabulary for use in air transport can be developed from existing taxonomies. Only minor modifications in the existing UMLS thesaurus are needed to rep resent clinical concepts appropriate to air transport. Funding. The Foundation for Aeromedical Research and National Library of Medicine

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AN ACTIVITY COMPARISON OF THE FIRST AND LAST 6 MONTHS OF AN AIR MEDICAL PROGRAM WITH 10 YEARS’ SERVICE JT Del Bello, BS, EMT-P: Franketta Zalaznik, RN, BSN, CCRN, UN University of Kentucky Aeromedical Services, University of Kentucky Hospital, Lexington, Ky.

EMPLOYEE SATISFACTION WITH A PEER REVIEW PROCESS Valerie Kiefer, Kenneth Robinson ’ LIFE STAR, Hartford Hospital, Hartford, Conn.

Introduction. Peer review is a process for practitioners to evaluate performance based on established standards and to strengthen group communication. The purpose of this study was to evaluate employee satisfaction with the current peer review process and to Introduction. The service began operation August 27, 1987. It operates a single helicopter in a rural and suburban population and is affiliated with a Level I trauma center. determine differences in satisfaction among the crew disciplines. Methods. Flight nurses (FNs), respiratory therapists (FITS), and communication speciaiEvaluation of the program is essential to successful fiscal and operational planning. This study compares the activities of the first and last 6 months of operation, I ists (CSs) were asked to complete a satisfaction survey that used a Likert scale (1 to 5). A total of 27 surveys were distributed and completed (FN = 10, RT = 10, and CS = 7). A Method. Flight records were obtained from September 1, 1987, to February 29, 1988, and September 1,1996, to February 28, 1997. Data collected include number of service I value of 3 on the Liked scale represented satisfaction. The mean for each group was de missions, missed missions, team interventions, and completed flight types for each 6termined, and the data were analyzed using a one-way ANOVA test. Results. The RTs (4.2, SD * 0.78) were the most satisfied, followed by the CSs (3.6, SD month period. The service missions, missed missions, and interventions were analyzed * 0.74) and the FNs (3.3, SD 2 0.78). Using a one-way ANOVA, the difference in the level using the Student r-test and the null hypothesis: the means for each is the same. The percentages of flight type were calculated and compared. of satisfaction among the three disciplines was determined not to be statistically significant. Although all groups appear to be satisfied, the largest difference was between the Results. No difference exists between flight mission means for the two periods (p >0.2). The null hypothesis, no difference exists between missed mission means for the two pe FNs and the RTs. Conclusion. All three disciplines seem to be satisfied with the current peer review riods, is rejected (p t0.005). No difference exists between intervention means for the two periods (p>O.2). Cardiac (38.94%) trauma (16.42%) and neurosurgery (13.47%) flight process, but the RTs were the only group with a mean score greater than 4. This shows types compose most missions (68.83%) during the first period. Trauma (38.51%) carpotential for improvement among the FNs and CSs. Further studies need to be performed to identify areas for improvement with the process. disc (17.23%). neurosurgery (8.08%), pediatrics (8.08%) and pulmonary (744%) flight types compose most missions (79.34%) during second period. Conclurlon. This service is operating close to its maximum service level. Demand has remained steady or increased during the 10 years, The level of patient acuity is steady. Little diversification has existed in flight types. The apparent reversal of cardiac and trauma flight percentages is explained by the Level I trauma designation,

IMPLEMENTATION

OF A PEER REVIEW PROCESS

EFFECT OF TRAUMA REGULATIONS ON TRAUMA PATIENT TRANSPORTS

Valerie Kiefer, Kenneth Robinson LIFE STAR, Hartford Hospital, Hartford, Conn.

Michael Zanker, MD; Kenneth Robinson, MD; Lenworth Jacobs, MD, MPH, FACS LIFE STAR, Hartford Hospital, Hartford, Conn.

Introduction. The peer review process strengthens group communication and professional relationships, stimulates personal and professional development, and promotes accountability. Because of these positive aspects, we implemented a peer review process, Methods. A peer review process for our program was implemented in phases, beginning in October 1996. Flight nurses were the first to enter the process. The second phase began in December 1996 and included respiratory therapists and communication specialists. The third and final phase was initiated in March 1997 and included pilots. Each discipline of our program, in conjunction with the continuous quality improvement work group, developed its own peer review form and procedure and accomplishes peer review within the guidelines of its unit. Results. A peer review process for the flight crew was successfully implemented through the continuous quality improvement work group and the program disciplines. The peer review process has fostered better communication within specific disciplines and continues to evolve. Revisions are implemented as needed. Conclusion. The peer review process has enabled our program to increase communication within each discipline. This process continues to evolve. The next step is to imple ment an interdisciplinary team review to enhance crew resource management and strengthen the team concept among the flight crew.

Introduction. On October 1, 1995, our state initiated a set of regulations dictating the field triage of acutely traumatized patients to designated trauma centers. Total annual flight volume for our program Is approximately 1000; approximately 55% are trauma related, and 45% are scene calls, The purpose of this study was to determine the impact of these trauma regulations on our program’s trauma-related call volume. Methods. All requests for helicopter transport of trauma patients were analyzed using our computerized flight registry. The Ill-month period after instituting the regulations was compared with the previous ll-month period, Results. Trauma-related requests were broken down by type of call (scene versus interfacility). p values were calculated based on the percentage of all requests and the percentage of all trauma-related requests, No statistically significant differences were noted in scene call volume or interfacility ICU transfers, but a significant difference was found in the inter-facility ED to ED call volume (p = 0.022). Conclusion. The fact that our scene volume did not change as a result of instituting our state’s trauma regulations suggests we previously had trained the prehospital care providers to appropriately use air medical transport, Further studies are necessary to de termine the etiology of the decrease in ED to ED trauma transports.

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EFFECTIVENESS OF COMPREHENSIVE SAFETY TRAINING

Dianne Murphy, Alex Markwell, Dawn Lawlor, Ed Phillips Rocky Mountain Helicopters/LIFE STAR, Hartford Hospital, Hartford, Conn. Safety remains a high priority in the air medical transport industry, but accidents still occur. A program-wide commitment to standardized safety training of all crew members may affect their response to an in-flight or helipad emergency. The flight crew-RNs, RTs, pilots, and communicators-had received some form of safety training before completing the safety course. Methods. A pretraining survey evaluating the flight crew’s confidence and knowledge of aircraft- and helipad-related emergencies was administered. A 24-point questionnaire based on the 5point Likert scale was used with a value of 4 = confidence. A comprehensive training program then was conducted. Flight crew members were asked to complete the same questionnaire 1 month after training. Follow-up evaluation using the same ‘24. point survey will be completed at 6 months and 9 months. Results. Pretraining survey results showed 56% to 94% confidence level with knowledge of and ability to perform safety procedures. Posttraining survey showed 81% to 96% confidence. Conclusion. Flight crew members with previous safety training demonstrated an increase in confidence to describe and perform safety procedures in emergencies as a resuit of our comprehensive safety training program. This success indicates a need for program-wide commitment to recurrent safety training. Future studies could enable the air medical transport industry to develop a standardized safety training program. Introduction.

IS OUTREACH EDUCATION AN EFFECTIVE MARKETING TOOL?

Debra Kickirillo, RN, BSN; Diana Taylor, RN, MSN Pediatric Transport Services, Children’s Medical Center of Dallas, Dallas, Texas The goal of outreach education (OE) is to expand the referral (ref.) base and improve patient (pt.) outcome while drawing attention to the transport program (TP). An increase in DE presentations (pres.) to a ref. should increase transports from that institution (inst.). The purpose of this study was to determine if OE is effective in marketing a TP. Methods. Data were collected retrospectively from January to December 1996. Each ref. in which an OE pres. was performed was identified by date. The total number of transports from that ref. that were completed 2 months before and 2 months after each OE pres. was tallied for the 12 months. These calculations were used to identify if a general increase occurred in refs. from that inst. after an OE pres. Also, gross revenues were measured for transports from those refs. before and after the pres. Results. Twenty-two OE pres. were done in 1996. Overall, a 21% increase occurred in the number of transports from refs. 2 months after compared with 2 months before the OE pres. The estimated growth in gross revenues as a result of increased volume was $63,840. Conclusion. OE helps increase a TP’s ref. base by increasing the volume of transports from the ref. after the OE pres. With increased volume, revenue generally increases. An important avenue for further research would be to measure improvement in pt. outcome with OE. Introduction.

Al4

WEIGHT ESTIMATION IN SIMULATED OLDER CHILD TO ADULT TRAUMA PATIENTS BY EMERGENCY HEALTH CARE WORKERS

Angela Fiege,’ RN; David Nelson2 Life Line,’ Methodist Hospital,* Indianapolis, Ind. Many emergency interventions are based on patient werght (pt. wt.). The purpose of this study was to measure the accuracy of pt. wt. estimation (pt. wt. est.) in older i child to adult trauma patients by a sample of emergency health care workers (EHCWs). 1 Methods. Five test subjects (gender-age in years: m-10, m-14, m-42, f-50, f-55) were placed in full spine precautions in enclosed rooms. EHCWs of varied training levels were asked to make pt wt. est. on each simulated trauma patient in pounds and kilograms before proceeding to the next room. Percent error and pound to kilogram conversion error were measured. The relationship between the demographics of EHCWs and misestima’ tion in pt. wt. was examined. Results. Fifty-one EHCWs participated. Overall percent error in pt. wt. est. was 10.3% in pounds (15.9 Ibs.) and 12.0% in kilograms (8.4 kg). The average error in pt. wt. est. was less than actual weight in all test subjects, with greatest misestimation in the heaviest (average = -12% actual wt., p tO.OO1) and lightest (average = -6% actual wt., p = 0.02) test subjects. The average ratio of pounds to kilograms was 2.3, not statistically significant. A trend among MDs was to be more accurate than RNs, EMT-Ps, and medical stu~ dents in the EHCW sample. Conclusion. EHCWs misestimate the weight of simulated older child to adult trauma patients. Est. pt. wt. errors can affect clinical response to weight-dependent emergency interventions. Introduction.

AN EDUCATION PROGRAM TO IMPROVE ADVANCED LIFE SUPPORT AND CRITICAL CARE INTERCEPTS OF BASIC LIFE SUPPORT AMBULANCES

Joseph B. Hejlik, RN, BSN; Patricia A. Malloy, RN, EMT-P; Daniel G. Hankins. MD, FACEP Mayo Medical Transport Services, Mayo Medical Center, Rochester, Minn. Basic life support (BLS) transports to this tertiary hospital average 30 minutes. Patients with time-dependent illnesses/injuries may be compromised. An education program was devised for BLS ambulance services about intercepts (ALS ground or critical care [CC] rotor-wing) in terms of level of care, safety cost, time, and distance. (Right crew and vehicle to right patient at right time.) Methods. A program was developed to train BLS selvices about intercepts by ALSICC. Cost comparisons of ALS ($180) versus CC ($3000) were presented. Predesignated landing/meeting zones were established. Minimizing transport of patients to the hospital under red lights/siren was emphasized. The number of intercepts before and after the program began and interventions performed by the ALSiCC crew were examined. Results. Seventeen BLS services received this program. In 1995, 26 ALS ground intercepts occurred; nine of 26 were patients in cardiac arrest. In 1996, a total of 66 intercepts occurred (four were cardiac arrests). ALS interventions Included cardiac monitoring, intubation, multiple medication administration, and fluid resuscitation. In 1995, 99 scene requests were made for the helicopter, a number equaled in 1996. CC interventions included tube thoracostomy, rapid sequence intubation, blood resuscitation initiation, central line placement, and administering medications not carried by ALS. Conclusion. The education program resulted in an increase of ALS Intercepts but did not change CC intercepts. Patients had earlier advanced assessment and interventions than otherwise during BLS transports. Introduction.

October-December

1997

16:4

Air Medical

Journal

BENEFICIAL EFFECTS OF CONTINUOUS INFUSION VECURONIUM IN INTUBATEO

THE USE OF FLIGHT NURSES IN OFFERING MEDICAL ASSISTANCE

PEDIATRIC CRITICAL CARE TRANSPORT PATIENTS

TO COMMERCIAL AIRLINES Judy Helgerson, RN; David Claypool, MD

Kimberly

Mayo Medical Transport Services, Mayo Medical Center, Rochester,

Minn.

Jr., MD, FAAP; David Patton, RN;

William D. King, RPh, MPH, DrPh

Introduction. Some commercial airhnes have identified a need to offer their customers and employees high-quality medlcal assistance during emergencies in flight because conventional emergency

H. Copeland, MD; William E. Hardwick,

care is not easily available. Diversion to an airport can be incon-

venient, sometlmes impossible, and is often unnecessary. In 1995 our program began an In-flight assistance service for a major airline. A flight nurse, under the direction of an

Department of Pediatrics, University Background.

Neuromuscular

of Alabama School of Medicine, Birmingham, Ala.

blockade frequently

IS used in critically ill patients requiring

mechanical ventilation to increase the efficiency of ventilation and oxygenation. This report evaluates the use of continuous infusion versus intermlttent bolus vecuronium for neuromuscular blockade during pediatric crittcal care transport Methods. Patients were recruited from the Children’s Hospital critical care transport

pop-

EMS physician, takes calls from the airline and offers appropriate advice. Methods. Information regarding all calls is recorded on a central database that is completed as the call is taken. Using this database, we looked retrospectively at calls taken,

ulation, enrolled in a prospecttve unblinded fashion, and randomly assigned to receive either a continuous vecuronium infusion (Group A) or intermittent boluses of vecuronium

how often the service was used, for what types of medical problems, how often diversion

(Group 6). Muscle relaxation was measured by train of four (TOFC) stimulus of the ulnar

was recommended, and treatments advised. Results. During 1996 the total number of calls we received was 243. Of these, diversion

nerve-adductor pollicis system. All patients received an initial O.lml/kg bolus of vecuronium and a standardized regimen of Midazolam. Group A received a continuous infusion

was recommended

of vecuronium

for 14.8%, with chest pain the most common symptom

requiring di-

version. The most common medical complaint was nausea and vomiting, which only requlred diversion once. We authorized opening the emergency medical kit on 40.7% of the flights. The most common complaint from medical personnel was difficulty commu-

starting at O.OGml/kglhr and adjusted up or down by O.Olml/kg/hr

on TOFC. Group B received additional drug (O.iml/kg) at 15-minute intervals 1 TDFC. Vital signs and TOFC were measured every 15 minutes. Results.

based

based on

In patient groups matched by age and weight, results were no difference in total

nicating with the aircraft

/ drug required, no difference in variation of heart rate between groups, and no difference

Conclusion. This service benefits the airline, their customers, and our program. We beheve customers and employees of the airline were helped in difficult circumstances

i in variation of systolic or diastolic blood pressure between groups. Conclusion. No significant difference exists in total drug required for neuromuscular

when conventional

medical assistance was not available. The specialized nature of flight

nursing appears uniquely suited to this task. Better communications to be developed.

SUCCESS AND COMPLICATIONS

technology

OF RAPID SEGUENCE INTUBATION (RSI) USE BY AN AIR MEDICAL SERVICE

Elizabeth Slater, RN, MSN, EMT-P; Steve Weiss, MD; Amy Ernst. MD Vanderbilt LifeFlight, Vanderbilt University Medical Center, Nashville, Tenn.

and to evaluate the value of prehospital use of RSI. Methods.

This study is a 31.month Subgroup

retrospective

review of all patients intubated and

analysis was based on transport

type and intubation

location.

Age, Glasgow Coma Score, type of call, scene time, and prior attempts also were recorded Complications included failure, multiple attempts, arrythrnias, and repeated paralytic. Comparisons

were made using a confidence interval analysis. A power of 0.05

was considered significant.

Bonferoni correction

infusion and in level of paralysis provided.

BENEFITS OF A RECEIVING CUSTOMER SATISFACTION SURVEY Juha Fultz, RN; Carlos Coyle, EMT-P; Patrick Reynolds, EMT-P University of Kentucky Air Medical Program, Lexington, Ky.

Introduction. Maintenance of an airway in the air medically transported patient is of paramount importance. The purpose of this study is to compare preflight versus en-route RSI

transported.

blockade between bolus and continuous

needs

was used for multiple comparisons.

Introduction. Air medical services are unique in that three groups of customers exist: the patient, the referring customer, and the receiving customer. This project evaluated the needs, concerns, crew. Methods.

and perceptions

of the customer

receiving the patient from the flight

Surveys, which were mailed to 300 receiving customers,

ments evaluating selvice performance,

consisted

of state-

questions regarding the transfer of patient infor-

mation, the patient’s postflight treatment plan, and overall customer

satisfaction.

Two ad-

ditional questions requested comments and/or suggestions for improvement. Results. Of the 300 surveys mailed, 161 were returned (54%). Results indicated receiving customers

are satisfied with the service provided. Comments were divided into posi-

Results. Of the 325 patients enrolled, 288 were intubated using RSI (89%). The success rate was 97%. No significant differences existed between the groups for number of failures (g/288), arrythmias (15/288), or repeated paralysis (8/288). Multiple attempts were

tive comments and suggestions for improvement. Three themes evolved from the suggestions for improvement: patient care issues, information transfer, and flight appropriateness.

performed in significantly more scene-preflight cases (35% 30186) than scene en-route cases (24%, 15/62). Even for cases having prior attempts, the success rate using RSI

Conclusion.

was 93% (62167). Conclusion. We had a very high success

rate for intubations

despite varied patient

groups. For scene calls, ground time decreased significantly and fewer multiple attempts were made when the intubation was en route versus preflight

Air

Medical

Journal

16:4

October-December

1997

Evaluating receiving

customer

satisfaction

provided

positive feedback

re-

garding their perception of the flight crew’s competence, proficiency, and professionalism. Suggestions for improvement provided insight into receiving customer perception of areas needing improvement. Suggestions of continuity and patient care coordination.

were an impetus to resolve important issues

Al5

AIRMEDICALEMSINANUNDERGRADUATLMEDICALCURAICULUM Janet Or-f, RN/MS; Stephen H. Thomas, MD; Suzanne Wedel, MD Boston MedFlight; Harvard Medical School; Boston University School of Medicine, Boston, Mass, Introduction. Medical students in many schools have been given little orientation to air medical EMS. This deficit is important to address because almost all medical students, regardless of their chosen residency specialty, eventually will send or receive patients by helicopter. Methods. A course in air medical EMS was added to a medical student rotation in emergency medicine. The following lectures are given by physicians: altitude physiology, medical direction, and controversies in air medicine. Flight nurses and medics address critical care transport, trauma scene management, and air/ground EMS coordination. The program administrator discusses public health and fiscal issues. Finally, an EMS pilot provides a brief introduction to aviation issues. Written evaluations were used to ascertain the success of the program in introducing students to the general principles of air medical transport. Resulb. Students have been very interested in the course and have noted they receive no other exposure to the subject of air EMS. Concluslon. Integration of an air transport course into undergraduate medical curricula was met with approval by participating students and appears to be an effective means by which the air medical industry can improve understanding of basic air transport principles.

Association of Air Medical Services

CALL FOR ABSTRACTS 1998SCIENTIFIC MEETING ALBUQUERQUE, NEW MEXICO October 26-28,199s The scientific program committee is calling for abstracts to be submitted for presentation at the 1998 Association of Air Medical Services (AAMS) Air Medical Transport Conference to be held at the City of Albuquerque Convention Center, New Mexico, October %28,1998. The scientitic session will address research topics related to the field of air medical transport F.vo types of pa pers will be considered for presentation. 1, SCIENTIFIC SESSION-Abstracts submitted to the scientific session will be reviewed for scientitic validity and the potential contribution to the air medical industry. The scientitlc sessions will be separated into two presentations, determined by the scores given to each abstract by the abstract review committee. The highest scoring abstracts will be presented together as a special session, scheduled in a manner so that everyone should be able to attend. These papers will be eligible for the AAMS Research of the Year Award. Each paper in the special session will be assigned a reviewer who will be invited to discuss the paper at the conference. A second session will be scheduled for the presentation of the remaining accepted abstracts. ‘Ihe au thors of abstracts accepted to the scientific session will be responsible for submitting a manuscript or extended abstract (3-5 pages) for review. The manuscript will be used by the assigned discussants, although this does not constitute submission to a journal. The authors retain the right to submit their manuscript to the journal of their choice. 2. EXPERIENCES AND INNOVATIONS SESSION-Abstracts from this category will be reviewed based on the knowledge that can be gained from others’ experiences and from the development and/or implementation of innovative ideas or methodologies in the air medical profession. The Experiences and Innovations Sessioncan provide the audience with valuable practical and experiencebased information, as well as foster futuristic thinking and development of innovative strategies to improve the indus try. The program committee will determine in which session an abstract will be presented. Oral presentations or poster presentations also will be determined by the program committee. Abstracts will be required to meet format criteria and must be typed on an original AAMS abstract form provided. All abstracts will be evaluated by members of the scientific program committee, who will be blinded to authorship and institutional afliliation. Al6

October-December

1997

16:4

Alr Medical

Journal