Informational presentation on history of ambulances, evolution of the industry of medical transport and transition to air medical transport

1. Maggie O’Donnell BSN CEN EMT-P CMTE
September 2014

3. History of Pre Hospital Care

4.  Para-medicines roots grow from military actions
 Paintings of Ancient Roman battle fields suggest some
warriors cared for wounded soldiers
 Modern warfare produced the military battlefield ambulance
corps medic.
 These physician extenders provided advanced first aide to
wounded soldiers until transported to a field hospital

5.  1966 The White paper “Accidental Death and Disability: The
Neglected Disease of Modern Society”
› U.S. researchers concluded that servicemen wounded in battle had
better rates of survival than motorists injured on California freeways
› This inspired the first experiments with use of civilian Paramedics in the
U.S.
 1973 Congressional Emergency Medical Services Systems Act
allowing for access to federal funding
 1975 AMA accepts and approves the EMT-Paramedic role as
an emergency health profession
› The DOT is responsible for establishing the training requirements of
Paramedics and EMT’s

6.  Two main types of EMS services were created
› Hospital based programs with some medical training
provided by the sponsoring hospital
› Funeral homes with volunteers who had little or no training
in first aide or medical care, providing transport with use of
the hearse

7. History of Ambulances

8.  Hammocks were readily available and used for centuries.
 In Roman and Greek times chariots served as ambulances
 In 1100 A.D. the Normans arrived in England with the
innovative horse litter
Modern Day
Hammock
Ambulance

11.  The first motorized ambulance appeared in 1899.
 The ambulance had a top speed of sixteen miles an hour.
 Ambulances had two horsepower electrical engines with
capability of traveling as far as twenty to thirty miles.

14.  Rapid advancements took place in the late 1950s to 1960s
allowing for basic patient care by an attendant while being
transported to a hospital
 Physicians came to realize that treatment at the scene
could make a difference between life and death.

16. The modern day ambulance comes in many shapes and sizes
Convalescent to Critical & Specialty Care

17. History of Air Ambulances

18.  The first known Air Medical Transport vehicle was invented by
Chief of Dutch Medical Services, deMooy
› deMooy realized surface transport was a major cause of death to injured
combatants. He devised a stretcher suspended from a hot air balloon
drawn by horses
 The hot air balloon air medical transport was used during the
siege of Paris in 1870
› 160 wounded French soldiers were successfully transported

19.  Shortly after the Wright brothers successfully flew their first
airplane, two US Army medical officers designed an airplane
to transport patients.
 The worlds first modern air ambulance was flown at Fort
Barrancas, Florida, in 1910.
› Unfortunately, on its first test flight, it flew only 500 yards at an altitude of
100 feet before crashing.

20.  The first fixed wing air ambulance used by military was during
World War I in 1915
› A wounded French soldier was evacuated from Serbia by airplane.
 1918 the U.S. Army modified a Curtiss JN-4D to carry patients
on a liter strapped to the rear cockpit.
› The rear cockpit was modified to accommodate a standard Army
stretcher carrying an injured person in a semi-reclined seat

22.  The first civilian air medical transport was completed in 1928
when a DeHaviland Fox Moth aircraft in the service of
Australia's Royal Flying Doctor Service took off on its first
mission.
DeHaviland Fox
Moth circa 1940

23.  War soon demonstrated the necessity of air evacuation.
 The Burma Hump airlift operation saw what was probably the
first use of helicopters for combat rescue
› Airplane downed 100 miles behind enemy lines, remote and inaccessible
area

24.  The first dedicated use of helicopters for air medical transport
was by the U.S. Government during the Korean war 1950 -
1953
Bell Helicopter in
Korea circa 1950
Patients carried
outside aircraft,
no medical care
in transit

25. Transition to patient
carried inside aircraft
with field medics or
nurses providing patient
care
The Huey Helicopter served as the blue print for
BK 117 Civilian Aircraft

26. Modern day helicopter ambulance also comes in many different
shapes and sizes

27. Roy Morgan, Air Methods'
founder, was the pilot who
flew the first St. Mary's air
medical team Flight for Life,
of Denver Co. established
1972
Flight For Life began with a
single Alouette III helicopter

29. The modern day medical transport team

30. Safety and Transport

31.  World War II
At the beginning of World War II, the common belief was air
evacuation of sick and wounded was dangerous, medically
unsound, and militarily impossible.
 The Army Medical Department did not believe the airplane
was a substitute for field ambulances, even when it was
necessary to evacuate casualties over long distances

32. Calendar Year 2003
19 Accidents
7 Fatalities
Calendar Year 2004
13 Accidents
18 Fatalities
Calendar Year 2005
15 Accidents
11 Fatalities
In the 11 month period between December 2007 – October 2008
9 Fatal Accidents resulting in 35 Deaths
Testimony of Robert L. Sumwalt Board Member NTSB before the subcommittee on
Aviation Committee on Transportation and Infrastructure United States Hose of
Representatives
Calendar Year 2006
13 Accidents
5 Fatalities
Calendar Year 2007
11 Accidents
7 Fatalities
Calendar Year 2008
13 Accidents
29 Fatalities

34.  After a spike in air ambulance crashes in the United States,
the U. S. Government implemented more stringent
regulations for operation of air medical services.
 The Commission on Air Medical Transportation Systems
(CAMTS) continues to review and implement standards
focused on patient and flight safety.
 CAMTS Accreditation is generally voluntary although some
states require accreditation

35.  No one holds more regard for safety of transport than the
transport crew
› Transport is an unstable environment many precautions are taken to
ensure safety
 Crew members are experts in the realm of patient transport.
 Decision on of mode of transport considers many factors
beyond physician request
› Crew configuration
› Crew capabilities
› Access to specialized equipment or treatments in transit
› Time to complete transport
› Time for patient out of hospital
› Distance, terrain, physical environment
› Appropriate utilization of resources

36.  Aircraft
› TAWS
› Weather Radar
› Wire Cutters
› Auto Pilot
› NVG
› Satellite Tracking
 Crew
› Helmets
› Nomex flight suits
› Radio communication between all crew and Flight Comms
› Regular aircraft safety briefs
› Regular Pilot check rides and simulator training
 Procedures
› Fire guard
› Tail guard for hot load
› Q 10 minute position checks
› Weather check prior to mission acceptance regardless of weather
conditions

37. Trauma? Critical Care? Specialized care to patient bedside? Need to move?

38. Ambulances
are mini ICU’s
and
Emergency
Departments

39.  Trauma
 STEMI
 Stroke
 Vascular Emergencies
 Specialty Care Teams
› Peds / Neo
› Physicians – Donor services
› Perfusionists

40.  Surgical emergency
› General
› Orthopedic
 Neurologic emergency
› Head bleed
› Increased ICP
 Medical Emergency
› Respiratory failure
› Sepsis
 A need for specialized
equipment, medications,
or treatments
› IABP
› ECMO
› Oscillator Vent
› Nitric
› Surfactent
› Blood

41.  Not all patients flown are critical or time sensitive
› Distance, a need to move (Thru put), or available resources contribute to
choosing air vs. ground transport
› Remote, sparsely populated areas which may be inaccessible by road
for months at a time benefit from air ambulance transport
 Fixed-wing vs. Ground
› Cost difference
 Rotor-wing vs. Fixed-wing
› Cost difference

42.  Crew skills set considerably greater than street medics or
nurses with hospital ICU background
› Allows ability to exercise more latitude in medical decision-making
 Skills may include advanced treatment typically performed
by physicians
› EKG or x-ray interpretation leading to treatment plan determined by
crew
 Some systems operate almost entirely off-line, using protocols
› On line medical control accessed when protocols have been exhausted

43. How do we interact with other healthcare entities

44.  It’s a pre hospital ambulance –
› Scene call activation is as second responder, must be requested by
another entity
› In North Carolina 911 centers will contact the service directly
 Some areas have centralized dispatch
 It’s an inter-facility ambulance –
› Physician or designee contacts service for request to transport
› Primary transport is from lower level of care to higher level of care
› Back transport is from higher level of care to lower level of care, or a
lateral transfer
 Difference is applicable only for billing
 Carolina Air Care implemented Transport Coordinator function to interact with
UNC’s Transfer Center

45.  Scene calls – goal is to dispatch closest available aircraft
› How do we know which aircraft is closest and in service while minimizing
time to procure resource
› Destination is to closest appropriate facility
 Inter Facility – tends to be associated with hospital
relationships, hospital systems, or perceived closest aircraft
 What if there is no aircraft available
› Program relationships
› Search alternate resources
 How does weather affect resource utilization
› Front side or back side of weather?

46.  Co-Opetition vs. Competition
› Air Medical Transport is becoming competitive
› Over built in some regions
› Collaborative relationships are essential
 North Carolina Air Medical Association
› Established 1986 by existing Hospital based flight programs in NC
› NCAA sets an example in how other regions could operate
› Mutual Aid agreement between agencies to cover transports unable to
be completed by requesting program

48.  Medical Transport has multiple levels of care available
 Patient billing based upon level of care provided
› Emergency or Non –Emergency indicates ambulance was dispatched as
soon as it was available or mission was pre-scheduled
› BLS – Basic Life Support – minimal treatment required
› ALS – Advanced Life Support – Advanced medical treatment required by
one provider
› ALS 2 (a.k.a. Critical Care) – Advanced Life Support – Significant
advanced medical treatment required by more than one medical
provider, ALS procedures performed
› SCT – Specialized care or team – Specific team configuration required or
utilization of highly specialized equipment
 Nitric
 IABP
 ECMO – Physician at bedside to perform procedure

49. Fly Safe