Air medical transport : An emergency and critical task which might be very challenging for health care workers specially in developing countries like India

1. Air Medical Transport
Presenter : Dr Ravi
Moderator : Dr Rafat Shamim

2. Introduction
• Factors deciding the mode of transportation :
a. Accessibility
b. Time
c. Distance
d. Criticality

3. Air Medical Transport
• Air Medical : use of aircraft for evacuation of patients
• Aeromedical : study of effects of flight & altitude on humans

4. Tools for Air Medical Transport
• Helicopters
• Fixed wing aircrafts

5. Fixed wing or aero plane type air ambulance:
• It is usually used for long distances inter-hospital patient transfer for
approximately more than 240 km.
• It is more rapid mode of transport with the provision of pressurized
cabin and less noise and vibration.
• The main disadvantage is requirement of additional ground transport
between the hospital and the air facility

6. Rotor wing or helicopter ambulance:
• It can be used for shorter travel distances of about 80 km.
• It can be used to transfer the patient directly to the receiving hospital
with the facility of helipad.
• There is no requirement of additional ground transport.
• space is more compact with interference of noise and vibration
during patient transfer.

7. Helicopters(Rotor-Wing) Transport
• Helicopter first flown on September 14th
, 1939 used for first rotor-
wing medical evacuation in Burma in 1945
• In the Korean war, 20,000 patients were transported by helicopter in
Korea
• Helicopters were a big factor in reducing combat- related mortality
successively from World War II through Korea and then in Vietnam

8. Civilian Rotor-Wing Transport
• First hospital based civilian program began in 1972 in Denver
• Most of the programs are run by hospitals or group of hospitals
• Most programs lease their helicopters from aircraft vendors to who
deal with multiple programs b/c of high cost of purchase, high cost of
maintenance, and the cost of maintaining pilot training
• Total no. of patients transported in US by rotor-wing crafts since 1972
is on the order of 7,50000 to 10,00000 yearly

9. Crew configuration and training
• The medical crew on a rotor wing can be configured in multiple ways :
i. Nurse – paramedic
ii. Nurse- nurse
iii. Nurse- physician
iv. Nurse- respiratory therapist
• Addition of a physician to the crew does not add a significant higher
level of care
• The most commonly used crew is nurse- paramedics due to
complementary skills brought together by these two disciplines.

10. • Helicopters transport pt. at 2500-3500 Ft
• Noise, vibration and temperature changes of a rotor wing craft can
have marked effect on the patients condition
• Can make assessment of the patient more difficult than ground
transport

11. Inter-hospital and intra-hospital patient
transfer:
• The main aim in all such transfers is maintaining the continuity of
medical care.
• The decision to transfer the patient is based on the benefits of care
available at another facility against the potential risks involved.
• The decision to transfer the patient is taken by a senior consultant
level doctor after thorough discussion with patient’s relatives about
the benefits and risks involved.
• A written and informed consent of patient’s relatives along with the
reason to transfer is mandatory before the transfer.

12. Pre-transfer stabilisation and preparation
• The patient should be adequately resuscitated and stabilised to the
maximum extent possible without wasting undue time.
• During the preparation, patient’s A, B, C and D, i.e., airway, breathing,
circulation and disability, should be checked, and any associated
preventable problems should be corrected.

13. Airway
• The patients with possibility of airway compromise during transfer
should be electively intubated with endotracheal tube (ETT) with a
cuff which should be secured properly after confirming its correct
position.
• NG tube
• Cervical spine stablization

14. Breathing
• The ventilation should be adequately controlled with optimisation of
the arterial blood gas values.
• In the suspected pneumothorax, chest drain should be inserted
before transfer, especially before air transport.

15. Circulation
• Two wide bore
• any shock should be treated with intravenous fluids and/or
vasopressors.
• Availability of crossed-matched blood

16. Disability or neurological status
• Patients with head injury should have their Glasgow coma scale (GCS)
adequately monitored and documented before and during transfer
and before administration of any sedative or paralytic agent.

17. Guidelines of Air Medical Dispatch
by American College of Emergency Physician
• The air transport is indicated when the ground transport is
not feasible due to the factors such as
-time of transfer,
-distance to be travelled
-level of care needed
• Severe trauma patients with penetrating chest injuries, multisystem
injuries, crush injuries, age less than 12 years or more than 55 years
or patients with unstable vital signs

18. • Patients with acute coronary syndrome in urgent need of
revascularisation procedure, cardiac tamponade with haemodynamic
compromise.
• Patients due to receive organ transplant
• Critically ill high-risk medical or surgical patients, for example, those
on high vasopressors, special modes of ventilation, requiring
hyperbaric oxygen therapy or with surgical emergencies such as aortic
dissection with haemodynamic compromise.

19. Accompanying the patient
• It is usually recommended to have at least two competent personnel
accompanying the patient to be transferred.
• The care required by each patient during transfer depends on the
level of patient’s critical care dependency :
I. Level 0: It includes the patients who can be managed at the level of
ward in a hospital
II. Level 1: It includes those patients who are at risk of deterioration in
their condition during the transfer
III. Level 2: It includes patients who require observation or
intervention for failure of single organ system

20. • Level 3: It includes patients with requirement of advanced respiratory
care during the transport with support of at least two failing organ
systems.

22. • The existing guidelines from Indian Society of Critical Care Medicine
for intra- and inter-hospital transport of patient is an evidence-based
guideline developed for Indian scenario.
• These guidelines are similar to other international guidelines.

23. Take Home Message ..
• Transfer is an important but often neglected phase of continuing care
of a patient.
• ‘stabilize and shift’
• The guidelines could be modified