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International air medical transport
CLINICAL REPORT
International Air Medical Transport Part I: Methods and Logistics Wilfred F. Holdefer, MD; Arnold G. Diethelm, MD; Jeffrey 7". Tolbert
Abstract International air medical transport requires reliable equipment, skilled personnel and precise planning. A report is presented of an experience with 29 international transports. Details concerning equipment, personnel and logistics are presented, Introduction
International transport of some critically ill patients cannot be satisfactorily accomplished by commercial carriers. In July 1988, through the cooperative efforts of MEDJET International (Birmingham, Alabama) and the University of Alabama at Birmingham, Critical Care Transport Service, an international air medical transport capability was implemented. This report presents our experience with 29 international transports and details, equipment, personnel, and logistic considerations. Methods
MEDJET International I provides a British Aerospace Hawker 125 and a Lockheed JetStar 731 for international transport. The aircraft are based in Birmingham, Alabama. The Hawker has a cruising speed of 480 miles per hour at 41,000 feet, with an unrefueled range of 2,500 miles. This aircraft can accommodate two passengers in addition to the patient and a three-member medical team. The JetStar has a cruising speed of 535 miles per hour at 43,000 feet, with an unrefueled range of 3,000 miles. This aircraft can accommodate four passengers in addition to the patient and a three-member medical team. 6
Results and problem areas are discussed. This early experience demonstrates the capability for the repatriation of critically ill patients, and the evacuation of patients who require access to a level of care which may be unavailable outside the United States.
Both aircraft have dual global navigation systems, global air to ground communications capability, complete lavatory facilities, and auxiliary power units (APU) for maintenance of cabin environment and medical equipment during ground time associated with fuel stops and any unplanned delays at origination or destination. Cabin altitudes, above sea level, are usually maintained at 5,000, 6,500, 7,000 and 8,000 feet for aircraft altitudes of 35,000, 39,000, 41,000 and 43,000 feet respectively. Each aircraft is permanently configured for air medical transport. The configurations include a liquid oxygen system, air and vacuum sources, and ll5vAC and 12/24vDC power outlets. The liquid oxygen systems in each aircraft provide 21,500 liters of oxygen at 0-300 pounds per square inch (P.S.I.). During transport, ventilatory support, when required, is provided with either an IC-2A portable pneumatic ventilator (Bio-Med Devices, Inc.) or an LP6 electric ventilator (Aequitron Medical, Inc.). Two ventilators, two invasive and non-invasive monitoring systems, and four infusion pumps are used. Extra supplies are stocked on the aircraft, in addition to standard sup, plies that comein the transport packs.
Ice, coffee, bottled water, soft drinks, juice and crackers are also stocked on the aircraft. A cabin wall rail mount system facilitates safety, access and visibility during transport for electrical, oxygen, vacuum, and air outlets, and secures infusion pumps, flowmeters, blenders, and suction canisters. A custom transport stretcher, with self-contained oxygen, ECG-defibrillator, and an invasive or non-invasive blood pressure monitor is secured to a stretcher mount within the cabin. The IC-2A, which mounts on the custom transport stretcher, is used for ventilatory support during ground transport to and from the aircraft. The LP6 is used during air transport. Ventilation monitoring is accomplished using either a transcutaneous oximeter (TcpO2) (Novametrix Medical Systems, Inc., Model 807) or a pulse oximeter 0VIinolta Pulsox), an in-line end tidal CO2 m o n i t o r (Novametrix Capnograph, Model 1260), and peak pressures. Electrocardiograph and invasive or non-invasive blood pressures are monitored with digital and waveform displays using e i t h e r a Propaq 104 (Protocol Systems, Inc.) or Escort monitor (Medical Data Electronics, Inc., Model 101). The Journal of Air Medical Transport ° July 1990
CLINICAL REPORT
Personnel Pilots and ground support personnel of MEDJET International are based in Birmingham, Alabama. The standard medical team consists of a physician, registered nurse, and a respiratory therapist, all experienced members of the University of Alabama Critical Care Transport Service, Birmingham, Alabama.
Logistics Patient Management • Pre-Departure, B i r m i n g h a m . After the final itinerary is confirmed, the transport physician advises the referring physician of the arrival time at the referring hospital and ascertains the details of the patient's clinical status, any special interventions the patient may require during transport, and the number and relationship of those passengers who will accompany the patient during transport. Ground transportation at the referring hospital and, if possible, at the receiving hospital, is confirmed at this time. The transport nurse contacts the nurse or nursing unit caring for the patient in the referring hospital to obtain pertinent clinical information and current treatment plans, including special medications or infusions the patient may require during transport. • Pre-Departure, Referring Hospital. After assessment of the patient, all nece s s a r y i n t e r v e n t i o n s are accomp l i s h e d to provide appropriate stabilization for transport. The medical records are obtained and, if possible, the receiving physician and receiving nursing unit are notiffed of the patient's diagnosis and condition and the estimated time of arrival at the receiving hospital. The destination ground ambulance transport may be confirmed at this time. The transport nurse also contacts the transport coordinator to confirm the departure time from the referring hospital. °Pre-Arrival, Receiving Hospital. Following departure from the final fuel The Journal of Air Medical Transport ° July 1990
stop, contact is established with the destination handling agents to confirm arrival time, update patient information, and confirm ground ambulance availability.
• Pre-Departure, ReceivingHospital. When the transfer of care to the medical staff at the receiving hospital is completed, contact is established as soon as possible with the referring physician and hospital to confirm completion of the transport.
Passengers Passengers are required to sign a waiver of liability in order to accompany the patient on the flight. A medical briefing for the passengers is conducted by the referring and transport physicians to fully inform them of the potential risks of the transport for the patient, and to discuss interventions that may be employed should resuscitation become necessary prior to arrival at the receiving hospital. Also included are discussions of resuscitation versus no resuscitation and the intensity of resuscitation. Passengers are questioned concerning any medical conditions they may have that might pose a problem during transport. Once the passengers board the aircraft, an aircraft safety briefing is presented.
Ground Transportation Ground ambulance transportation is generally secured prior to departure from Birmingham. It is extremely important to establish the time and distance between airport and hospital, and also the time of day as related to traffic conditions. This is particularly important in the transport of ventilator patients. Although the custom transport stretcher contains three "E" cylinders of oxygen, extraordinarily long distances between an airport and a hospital may make it necessary to use oxygen onboard the ambulance. If there is no oxygen onboard the ambulance, then it is wise to carry extra oxygen cylinders.
Transports in which the origination or destination is within the United States usually present no problems with securing appropriate ground ambulance transportation. For those transports in which the origination or destination is in another country, ground transportation may be secured by either the airport handlers, family members, or referring or receiving physicians. Approximately 45 minutes to an hour before the aircraft has landed, the airport is notified by radio communication of the time of arrival, and the ambulance is notified of this time. When a transport involves an overnight stay at the origination point of the transport, the airport handlers arrange transportation for the flight and medical crew from the airport to the hotel. In most instances, the medical supplies, packs, equipment and monitors are taken to the hotel. Transportation between the .hotel and referring hospital is usually accomplished by cab or, in some instances, the referring physician will supply such transportation. The preliminary assessment of the patient is accomplished the day of arrival so that hospital time the next morning of departure is not excessive. On the morning of departure, the medical crew arrives at the referring hospital by cab, and the patient is then transported to the airport in a local ambulance.
Fuel Stops Airport personnel handle refueling of the aircraft at the intermediate fuel stops. The average time for refueling is between 30 and 45 minutes. During ground time, the cabin environment and medical equipment are maintained with the APU. At strategic fuel stops meals are put onboard the aircraft, and the passengers and medical crew may deplane. In general, the nurse and respiratory therapist will deplane while the transport physician remains onboard with the patient. Upon their return, the transport physician will deplane if necessary. 7
CLINICAL REPORT Crew Changes Pilot crew duty rest is accomplished according to FAA Regulations, 2 and depending on the flight times involved in each transport may or may not require a relief pilot for compliance with these regulations. When relief pilots are required prior to the destination, they are dispatched by commercial carrier to the appropriate fuel stop or stops to assume flight duties from the deplaning flight crew. After appropriate rest, the deplaned crew either returns home or dispatches ahead by commercial carrier to other fuel stops, if required, for extremely long transports. The same medical team accompanies the patient throughout the transport. Rest for the medical team is accomplished in flight with members of the team sleeping in a rotation where the transport nurse or physician is always awake with the patient.
All members of the medical team are within arms' reach of each other should a situation demand all three for intervention.
Customs T h e a i r p o r t p e r s o n n e l handle customs arrangements if the crew is to be overnight in either the city of origination or destination. In countries where there is a reciprocal visa agreement without inordinate advance norice, a temporary visa is issued on arrival and returned to customs upon departure. Strict customs inspections are enforced when re-entering the United States from a drug-trafficking country. When there is no overnight stay involved, there are usually no customs difficulties.
The second half of this article (Part II: Results and Discussions) will appear in our August issue.
FAA
Wilfred E Holdefer, MD, is associate professor of surgery and associate medical director of the Critical Care Transport service at the Univ. of Alabama at Birmingham Dept. of Surgery/Div. of Emerg. Services (Birmingham, AL). Arnold G. Diethelm, MD, is chairman and professor at the Univ. of Alabama at Birmingham Dept. of Surgery/Div, of Emerg. Services. He is also medical director at Critical Care Transport, based at the Univ. ofAlabama Hospital. Jeffrey T Tolbert is president of MEDJET Int'I (Birmingham, AL).
References 1. N u n e z J: P r o g r a m Profile: MEDJET International. Hospital Aviation 1989; 8(7):19-25. 2. Code Of Federal Regulations 1989; FA.R. 135.267, 135.269.
STC
720 APPROVED EMS INTERIORS Since 1979
Dedicated King Air Available For Lease 1-800-367-6637 O U T S I D E US (414) 544-9266 • FAX (414) 544-9378 E G A N A V I A T I O N INC • 5838 N 80th S T R E E T • M I L W A U K E E , Wl 53218 U S A
8
The Journal of Air Medical Transport • July 1990
International Air Medical Transport Part I: Methods and Logistics Wilfred F. Holdefer, MD; Arnold G. Diethelm, MD; Jeffrey 7". Tolbert
Abstract International air medical transport requires reliable equipment, skilled personnel and precise planning. A report is presented of an experience with 29 international transports. Details concerning equipment, personnel and logistics are presented, Introduction
International transport of some critically ill patients cannot be satisfactorily accomplished by commercial carriers. In July 1988, through the cooperative efforts of MEDJET International (Birmingham, Alabama) and the University of Alabama at Birmingham, Critical Care Transport Service, an international air medical transport capability was implemented. This report presents our experience with 29 international transports and details, equipment, personnel, and logistic considerations. Methods
MEDJET International I provides a British Aerospace Hawker 125 and a Lockheed JetStar 731 for international transport. The aircraft are based in Birmingham, Alabama. The Hawker has a cruising speed of 480 miles per hour at 41,000 feet, with an unrefueled range of 2,500 miles. This aircraft can accommodate two passengers in addition to the patient and a three-member medical team. The JetStar has a cruising speed of 535 miles per hour at 43,000 feet, with an unrefueled range of 3,000 miles. This aircraft can accommodate four passengers in addition to the patient and a three-member medical team. 6
Results and problem areas are discussed. This early experience demonstrates the capability for the repatriation of critically ill patients, and the evacuation of patients who require access to a level of care which may be unavailable outside the United States.
Both aircraft have dual global navigation systems, global air to ground communications capability, complete lavatory facilities, and auxiliary power units (APU) for maintenance of cabin environment and medical equipment during ground time associated with fuel stops and any unplanned delays at origination or destination. Cabin altitudes, above sea level, are usually maintained at 5,000, 6,500, 7,000 and 8,000 feet for aircraft altitudes of 35,000, 39,000, 41,000 and 43,000 feet respectively. Each aircraft is permanently configured for air medical transport. The configurations include a liquid oxygen system, air and vacuum sources, and ll5vAC and 12/24vDC power outlets. The liquid oxygen systems in each aircraft provide 21,500 liters of oxygen at 0-300 pounds per square inch (P.S.I.). During transport, ventilatory support, when required, is provided with either an IC-2A portable pneumatic ventilator (Bio-Med Devices, Inc.) or an LP6 electric ventilator (Aequitron Medical, Inc.). Two ventilators, two invasive and non-invasive monitoring systems, and four infusion pumps are used. Extra supplies are stocked on the aircraft, in addition to standard sup, plies that comein the transport packs.
Ice, coffee, bottled water, soft drinks, juice and crackers are also stocked on the aircraft. A cabin wall rail mount system facilitates safety, access and visibility during transport for electrical, oxygen, vacuum, and air outlets, and secures infusion pumps, flowmeters, blenders, and suction canisters. A custom transport stretcher, with self-contained oxygen, ECG-defibrillator, and an invasive or non-invasive blood pressure monitor is secured to a stretcher mount within the cabin. The IC-2A, which mounts on the custom transport stretcher, is used for ventilatory support during ground transport to and from the aircraft. The LP6 is used during air transport. Ventilation monitoring is accomplished using either a transcutaneous oximeter (TcpO2) (Novametrix Medical Systems, Inc., Model 807) or a pulse oximeter 0VIinolta Pulsox), an in-line end tidal CO2 m o n i t o r (Novametrix Capnograph, Model 1260), and peak pressures. Electrocardiograph and invasive or non-invasive blood pressures are monitored with digital and waveform displays using e i t h e r a Propaq 104 (Protocol Systems, Inc.) or Escort monitor (Medical Data Electronics, Inc., Model 101). The Journal of Air Medical Transport ° July 1990
CLINICAL REPORT
Personnel Pilots and ground support personnel of MEDJET International are based in Birmingham, Alabama. The standard medical team consists of a physician, registered nurse, and a respiratory therapist, all experienced members of the University of Alabama Critical Care Transport Service, Birmingham, Alabama.
Logistics Patient Management • Pre-Departure, B i r m i n g h a m . After the final itinerary is confirmed, the transport physician advises the referring physician of the arrival time at the referring hospital and ascertains the details of the patient's clinical status, any special interventions the patient may require during transport, and the number and relationship of those passengers who will accompany the patient during transport. Ground transportation at the referring hospital and, if possible, at the receiving hospital, is confirmed at this time. The transport nurse contacts the nurse or nursing unit caring for the patient in the referring hospital to obtain pertinent clinical information and current treatment plans, including special medications or infusions the patient may require during transport. • Pre-Departure, Referring Hospital. After assessment of the patient, all nece s s a r y i n t e r v e n t i o n s are accomp l i s h e d to provide appropriate stabilization for transport. The medical records are obtained and, if possible, the receiving physician and receiving nursing unit are notiffed of the patient's diagnosis and condition and the estimated time of arrival at the receiving hospital. The destination ground ambulance transport may be confirmed at this time. The transport nurse also contacts the transport coordinator to confirm the departure time from the referring hospital. °Pre-Arrival, Receiving Hospital. Following departure from the final fuel The Journal of Air Medical Transport ° July 1990
stop, contact is established with the destination handling agents to confirm arrival time, update patient information, and confirm ground ambulance availability.
• Pre-Departure, ReceivingHospital. When the transfer of care to the medical staff at the receiving hospital is completed, contact is established as soon as possible with the referring physician and hospital to confirm completion of the transport.
Passengers Passengers are required to sign a waiver of liability in order to accompany the patient on the flight. A medical briefing for the passengers is conducted by the referring and transport physicians to fully inform them of the potential risks of the transport for the patient, and to discuss interventions that may be employed should resuscitation become necessary prior to arrival at the receiving hospital. Also included are discussions of resuscitation versus no resuscitation and the intensity of resuscitation. Passengers are questioned concerning any medical conditions they may have that might pose a problem during transport. Once the passengers board the aircraft, an aircraft safety briefing is presented.
Ground Transportation Ground ambulance transportation is generally secured prior to departure from Birmingham. It is extremely important to establish the time and distance between airport and hospital, and also the time of day as related to traffic conditions. This is particularly important in the transport of ventilator patients. Although the custom transport stretcher contains three "E" cylinders of oxygen, extraordinarily long distances between an airport and a hospital may make it necessary to use oxygen onboard the ambulance. If there is no oxygen onboard the ambulance, then it is wise to carry extra oxygen cylinders.
Transports in which the origination or destination is within the United States usually present no problems with securing appropriate ground ambulance transportation. For those transports in which the origination or destination is in another country, ground transportation may be secured by either the airport handlers, family members, or referring or receiving physicians. Approximately 45 minutes to an hour before the aircraft has landed, the airport is notified by radio communication of the time of arrival, and the ambulance is notified of this time. When a transport involves an overnight stay at the origination point of the transport, the airport handlers arrange transportation for the flight and medical crew from the airport to the hotel. In most instances, the medical supplies, packs, equipment and monitors are taken to the hotel. Transportation between the .hotel and referring hospital is usually accomplished by cab or, in some instances, the referring physician will supply such transportation. The preliminary assessment of the patient is accomplished the day of arrival so that hospital time the next morning of departure is not excessive. On the morning of departure, the medical crew arrives at the referring hospital by cab, and the patient is then transported to the airport in a local ambulance.
Fuel Stops Airport personnel handle refueling of the aircraft at the intermediate fuel stops. The average time for refueling is between 30 and 45 minutes. During ground time, the cabin environment and medical equipment are maintained with the APU. At strategic fuel stops meals are put onboard the aircraft, and the passengers and medical crew may deplane. In general, the nurse and respiratory therapist will deplane while the transport physician remains onboard with the patient. Upon their return, the transport physician will deplane if necessary. 7
CLINICAL REPORT Crew Changes Pilot crew duty rest is accomplished according to FAA Regulations, 2 and depending on the flight times involved in each transport may or may not require a relief pilot for compliance with these regulations. When relief pilots are required prior to the destination, they are dispatched by commercial carrier to the appropriate fuel stop or stops to assume flight duties from the deplaning flight crew. After appropriate rest, the deplaned crew either returns home or dispatches ahead by commercial carrier to other fuel stops, if required, for extremely long transports. The same medical team accompanies the patient throughout the transport. Rest for the medical team is accomplished in flight with members of the team sleeping in a rotation where the transport nurse or physician is always awake with the patient.
All members of the medical team are within arms' reach of each other should a situation demand all three for intervention.
Customs T h e a i r p o r t p e r s o n n e l handle customs arrangements if the crew is to be overnight in either the city of origination or destination. In countries where there is a reciprocal visa agreement without inordinate advance norice, a temporary visa is issued on arrival and returned to customs upon departure. Strict customs inspections are enforced when re-entering the United States from a drug-trafficking country. When there is no overnight stay involved, there are usually no customs difficulties.
The second half of this article (Part II: Results and Discussions) will appear in our August issue.
FAA
Wilfred E Holdefer, MD, is associate professor of surgery and associate medical director of the Critical Care Transport service at the Univ. of Alabama at Birmingham Dept. of Surgery/Div. of Emerg. Services (Birmingham, AL). Arnold G. Diethelm, MD, is chairman and professor at the Univ. of Alabama at Birmingham Dept. of Surgery/Div, of Emerg. Services. He is also medical director at Critical Care Transport, based at the Univ. ofAlabama Hospital. Jeffrey T Tolbert is president of MEDJET Int'I (Birmingham, AL).
References 1. N u n e z J: P r o g r a m Profile: MEDJET International. Hospital Aviation 1989; 8(7):19-25. 2. Code Of Federal Regulations 1989; FA.R. 135.267, 135.269.
STC
720 APPROVED EMS INTERIORS Since 1979
Dedicated King Air Available For Lease 1-800-367-6637 O U T S I D E US (414) 544-9266 • FAX (414) 544-9378 E G A N A V I A T I O N INC • 5838 N 80th S T R E E T • M I L W A U K E E , Wl 53218 U S A
8
The Journal of Air Medical Transport • July 1990