Air Assets - An In Depth Discussion

[Guest]

In light of recent events and discussion, i wanted to see if we couldn't centralize the questions and answers, to serve almost as a Q&A between the responders and some of those who are air-crew members. All questions, comments and the like are highly encouraged!

I'll start off with a few questions:

- Should we limit the use of air assets to victims of multi-systems trauma only? If not, what other services can an air asset provide our patients?

- How should we utilize the notion of "standby?" Should this be initiated at dispatch? Enroute to the job? Or would it be best to check availability and once o/s determine the need to launch the bird?

- What makes and how large should a proper LZ be? Should the ambulance stage outside the LZ and upon landing the ambulance move in to offload the patient?

- What special procedures can flight medics/nurses preform in the field that street resources cannot and should these procedures be a determining factor in calling the air asset?

- What can and what can you guys not preform in the back of a chopper? I've always been under the notion and have been taught that patients in traumatic / cardiac arrest cannot be transported via air due to their general instability. Is this true?

Edited May 15, 2007 by 66Alpha1

[Oswegowind 17]

A great view for one...j/k

On a serious note, air ambulances are used for non emergency transportation also whether it be helo's or planes. Sometimes it is more logical for a helo to be called especially if traffic could be a consideration. Although you should never wait for the helo, you need to make sure you can get where you are going in a timely fashion. As there is ALS interception involving a medic...there can be Aviation interception also!

Edited May 15, 2007 by Oswegowind

[STAT213 332]

In light of recent events and discussion, i wanted to see if we couldn't centralize the discussion. All questions, comments and the like are highly encouraged!

I'll start off with a few questions:

- Should we limit the use of air assets to victims of multi-systems trauma only? If not, what other services can an air asset provide our patients?

←

There are a few exceptions to the whole who should fly thing.

Criteria for Air Transport from a scene include: (from the DHART website)

Helicopter transport is recommended for the following:

* Head injured patients with one of the following:

*GCS less than 12 or deteriorating

*Focal neuro findings

* Penetrating injury or open fracture

* Patients with the following chest injuries:

*Possible tension pneumothorax

*Major chest wall injury

*Potential cardiac injury

*Penetrating chest wound

* Patients with unstable vital signs including hypotension, tachypnea, severe respiratory failure

* Burn patients with potential airway involvement

* Patients with spine injuries with neurologic involvement and potential airway/breathing compromise

3) Exceptions (patients who may require transport but do not meet the above indications):

* Long distance transports of critical patients (more than 2 hours by ground)

* Situations where resources at the sending facility are severely limited:

o Mass casualty situations

o Lack of availability of ground transport

o Lack of availability of critical care personnel to accompany patient

* Weather conditions that ground transport dangerous (e.g. icy roads but clear skies)

There are your exceptions.

RA

[STAT213 332]

"you should never wait for a helo"

Gotta disagree. Put it this way. If you can sit and wait for a helo for fifteen minutes, and they will get to the Level One center in 45 minutes vs. taking them to the local hospital where all they can do is scan them and secure their airway, and all that - including phone calls to the level one to get acceptance - takes 2 hours, sit and wait...its better for the patient.

Burns, same thing. Set up camp and wait. On some calls it is better. I promise!!

[Oswegowind 17]

Okay, maybe in a place far far away from a Trauma Center waiting is not so bad, but why not get on the move and meet them on the way? I mean, if an LZ can be coordinated on in which both units can meet safely...otherwise I am not big on sitting and waiting! Unfortunately if the patient dies and the ambulance was on scene awaiting the helocopter someone may have a bone to pick or lawsuit to settle. At least you got them to definitive care and to an MD and don't have to argue as to why you were hanging out at the scene...just my opinion though.

[STAT213 332]

"Stat, do these times include pre-flight? Does the clock stop when overhead or when you land? What's a realistic turn around time if the patient is waiting at the LZ?"

Those are average times for the flight to the scene. Generally add about 5 minutes for weather check and departure. A good on scene time is 10 minutes. By this, I refer to skid to skid times. We do look at these things, and try hard to improve. Like anywhere else, things don't always go the way you like them to.

I have had 5 minute skid to skid times. Some were longer. I can tell you as a flight medic, I was always worried about the times and destinations, because we were called to be quick, not to screw around on scene, and not to fly to a hospital someone could have driven to themselves.

Its not a perfect world, but its my world and I take a lot of pride in it.

Rob

[Guest paramedico987]

I have a thought on when to use an emergency choppa OTHER than "major trauma" so since you asked... I'll share.

Anyone who works with me knows that I HATE the helicopter. It puts countless extra lives in danger, is extraordinarily expensive, significantly interfere's with assesment and treatment during transport, and frankly DELAYS care in the areas that I've worked.

The notable exceptions as to when I HAVE and/or WOULD request a helicopter are as follows:

-MCI with pt's who are actually TIME CRITICAL that will have to WAIT on scene to get a bus there for transport [multiple time critical patients]. It's rare but it does happen. [the recent fatal MVA in Pleasant Valley sounds like it could potentially meet this criteria]

-Extreme rural setting with a patient that has actual TIME CRITICAL injuries [i.e. NOWHERE IN WESTCHESTER COUNTY] ...I've beaten the chopper's pt from the same MVA to the same hospital by ground transport of another patient from within Westchester.

-Long distance transport for a speacial needs facility.

Specifically [although I wasn't on the job] there was a hiker who sustained an envenomation from a timber rattler in Ward Pound Ridge Reservation. After an extended wilderness type extrication [911 was called from a cell phone about a mile into the woods] the patient was transported by ground to WCMC, who has NO TREATMENT for this patient. WCMC can treat envenomations... but they get thier antivenin by request from Jacobi or another source [most easily from the Bronx Zoo I would think], it's not stocked! (or at least it wasn't when this call came up in an audit)

For this patient the use of a helicopter to pluck them right off of the tree line and down to Jacobi Medical Center [the regional snake bite center] would ABSOLUTELY be justifiable and in their best intrest as the hemotoxic properties of this type of injury are very much time sensitive. At the very best,

time lost = tissue lost.

While it is REALLY COOL to watch the helicopter take off and land, and we get to sound all buffy on the radio, the real risk to benefit ration [specifically in Westchester] is not in favor of medivac use very often.

That being said, the helicopter is an incredibly valuable tool for a significant portion of New York State where a ground transport of a critically injured person could be upwards of 3 hours to a level 1 trauma center. I just don't like to see it used becuase of mechanism of injury alone.

That's my 2 cents on that matter

Edited May 15, 2007 by paramedico987

[Guest partyrock]

I fully understand the times involved in flying. I just wanted to get an idea as to what they are. They are a necessary reality to keep everyone safe and the birds flying.

The Bronx Zoo stores most (possibly all) of its anti-venom at Jacobi. More can always be harvested, but it takes time for collection and processing.

[64FFMJK 21]

While it is REALLY COOL to watch the helicopter take off and land, and we get to sound all buffy on the radio, the real risk to benefit ration [specifically in Westchester] is not in favor of medivac use very often.

That being said, the helicopter is an incredibly valuable tool for a significant portion of New York State where a ground transport of a critically injured person could be upwards of 3 hours to a level 1 trauma center.  I just don't like to see it used becuase of mechanism of injury alone.

That's my 2 cents on that matter

←

I have to agree with this statment as well for Dutchess County. Helo's and ALS ground are over used if not abused in Dutchess County on a daily bacis. I sit and wait forthe Helo request every time that East Fishkill gets a MVA. While yes they do have a long transport time to the hospital we all need to sit back and remember that Medivac while great when used properly and for the right reasons is still dangerous and the more it gets abused more greater the risk for an accident or crash. I am not saying not to use choppers but there also need to be a risk to benifit thought before saying send the chopper.

Also on those flight times I understand that yes the bird can be in the air and over the scene but also you have to take into concideration getting the LZ set up. If you go 3 dispatches thats already 10 minutes and this can and does happen with the dwindeling ranks of volunteers today.

[Guest]

How long does it take for East Fishkill to transport to a hospital?

You guys are nuts if you think you have long transports - Vanderbilt Medical Center in the South has ground transports from Fort Cambpell(45 minutes) and outlying counties in Tennessee(1 hour plus) all the time.

[xfirefighter484x 234]

I sit and wait forthe Helo request every time that East Fishkill gets a MVA.  While yes they do have a long transport time to the hospital we all need to sit back and remember that Medivac while great when used properly and for the right reasons is still dangerous and the more it gets abused more greater the risk for an accident or crash.

←

EFRS has a t-shirt that on the back reads:

IF IN DOUBT,

FLY EM OUT

EFFD does get some very serious MVAs, for example one on Route 216 last year, which required 3 medevacs.

Edited May 16, 2007 by xfirefighter484x

[EJS1810 7]

I'll start off with a few questions:

- How should we utilize the notion of "standby?" Should this be initiated at dispatch? Enroute to the job? Or would it be best to check availability and once o/s determine the need to launch the bird?

- What makes and how large should a proper LZ be? Should the ambulance stage outside the LZ and upon landing the ambulance move in to offload the patient?

←

We got a memo back when 40-Control was at PCSD that if the flight time was more then 15 minutes Stat Flight wanted to be launched rather then put on standby. I know I have a copy of it at home in my memo's file somewhere. I will have to look for it to see where it came from.

If I remember correctly the LZ should be a minimum of 60X60 durring the day and 100X100 at night. No One Goes Into the LZ until the aircraft is on the ground and they are instructed to do so by the flight crew. There was a recent incident where the driver of the ambulance thought she was giving door to door service from the wreck to the medivac.

Stage outside the LZ and wait for the Medivac crew to come to you or instruct you what to do.

Edited May 16, 2007 by EJS1810

[Guest]

We got a memo back when 40-Control was at PCSD that if the flight time was more then 15 minutes Stat Flight wanted to be launched rather then put on standby.  I know I have a copy of it at home in my memo's file somewhere.  I will have to look for it to see where it came from.

If I remember correctly the LZ should be a minimum of 60X60 durring the day and 100X100 at night.  No One Goes Into the LZ until the aircraft is on the ground and they are instructed to do so by the flight crew.  There was a recent incident where the driver of the ambulance thought she was giving door to door service from the wreck to the medivac. 

Stage outside the LZ and wait for the Medivac crew to come to you or instruct you what to do.

←

Thanks EJS...i remember that well, i think the pilot was rather upset as well If i also remember, i got hammered for bringing it up here.

[WAS967 97]

Specifically [although I wasn't on the job] there was a hiker who sustained an envenomation from a timber rattler in Ward Pound Ridge Reservation. After an extended wilderness type extrication [911 was called from a cell phone about a mile into the woods] the patient was transported by ground to WCMC, who has NO TREATMENT for this patient. WCMC can treat envenomations... but they get thier antivenin by request from Jacobi or another source [most easily from the Bronx Zoo I would think], it's not stocked! (or at least it wasn't when this call came up in an audit)

For this patient the use of a helicopter to pluck them right off of the tree line and down to Jacobi Medical Center [the regional snake bite center] would ABSOLUTELY be justifiable and in their best intrest as the hemotoxic properties of this type of injury are very much time sensitive. At the very best,

time lost = tissue lost.

Interesting call. How long ago was this? I've worked up here for 7 years and hadn't heard about that one. I'm actually rather shocked that WMC doesn't/didn't stock Crofab (the antivenin used for Crotalid bites, of which the timber rattler is one.) I'll have to make a few phone calls and see which hospitals in the area DO carry it. I'd imagine the two biggest hurdles to using it are 1) cost and 2) doctors being comfortable with actually using it.

Edited May 16, 2007 by WAS967

[Remember585 815]

Nothing is perfect, but we seem to settle on this statement instead of pursuing a better result.

Stat or any Medivac shouldn't be a consideration too far into your call. We have had the discussion of starting out fire resources based on information from dispatch, knowing your area, past incidents and other crucial factors.

If you know you have a ground transport time that is 2, 3, 4 or more times longer then a flight to WMC, then instead of WAITING until you or one of your units arrives and finds a helluva mess, have them ready to go sooner. I will admit that we have had the bird a few too many times when ground transport would suffice. It all comes down to knowing your area and the resources available to you.

Without traffic and assuming the driver is following all applicable laws, we can get to WMC in as little as 10 minutes. Do we need the chopper, probably not. Especially when it is a State Police unit that we can't communicate with, but that's a different topic.

I am not a Medic nor an ALS provider so my knowledge of what they can do is somewhat limited. I have been a BLS provider for nearly 14 years. There's been calls where we can credit STAT for being a part of the life-saving chain and there's been an equal, if not more, times where it's called and not really needed, and their crew would agree.

Take the time to learn what they can offer, host an outreach, I promise it will open your eyes.

[RWC130 594]

It's close to shift change, You are dispatched to a PIAA and you have tickets to a Yankee Game...... Call STAT Flight!

OK, all jokes a side. Having STAT Flight is a GREAT thing.

IT SAVES LIVES! No doubt.

I do have to agree with Remember585 about misuse of the chopper

at times. It happens and it should not.

[Guest paramedico987]

Interesting call. How long ago was this? I've worked up here for 7 years and hadn't heard about that one. I'm actually rather shocked that WMC doesn't/didn't stock Crofab (the antivenin used for Crotalid bites, of which the timber rattler is one.) I'll have to make a few phone calls and see which hospitals in the area DO carry it. I'd imagine the two biggest hurdles to using it are 1) cost and 2) doctors being comfortable with actually using it.

←

This was maybeeeeee around 1-2 years ago. Everyone involved was also a little taken back that WMC didn't have a stock. My recollection was that they had something sent up from Jacobi. The job didn't get a lot of press in the community. As far as care went, I'm told, routine ALS as a precaution. And I don't have any idea what the outcome for the patient was.

[Guest paramedico987]

Oh, also in terms of level of care...

I understand that Stat [now lifenet?] has 2 advantages in care level over standard als: RSI [i already have so not an advantage, plus in my experiance most people who need it in the field are going to die anyway] and REALLY COOL the I.O. gun thing that's just UBER-USEFULL for all kinds of vascularly challenged patients... but I suppose barring the need for meds in the field they could just as easily wait for the ER to get their central line placed.

[WAS967 97]

I called NWH and talked to one of the Pharmacists about the Crofab. They only keep 2 vials handy for first line use (initial dose can actually range upwards of 6-9 vials soooo). They cost a mere $2000 a vial so cost is Definatly an issue. I can imagine the same issue exists at the medical center.

As for the advantages of Lifenet with RSI, yeah they have that and it can be beneficial if an ALS agency does not. I know I have had patients where I wished I had RSI but didn't. Se la vie. As for the IO-Guns, there really is no reason that an agency can't carry them. They fall within the current ALS protocols in both Westchester and the Hudson Valley. They only need to be approved by the agency medical director and the agency needs to hold the appropriate in-service to get the providers up to speed. I think you will be seeing more agencies carrying them in the next few years. And before people go "woa woa woa....you're gonna be drilling needles into bones as a matter of routine?" - here's some videos for them to watch:

Real Call - BIG Use - http://www.waismed.com/upload/Media/Movies...%202007-700.wmv

EZ-IO Use on Live Person - http://www.vidacare.com/reports/Insertion%201.mpg

On the actual call, insertion takes about 2 minutes, but you can tell there is a little trepidation on the part of the person using. With comfort and experience the time can be cut easily in half.

Edited May 17, 2007 by WAS967

[firemoose827 324]

Interesting topic, one that I have had mixed feelings about for YEARS now. I have read a lot of your posts and most of you talk about the need for life net and whether or not it is overused. This is interesting to me because I have taken the outreach training put on by Life Net out of Albany, and the medic who spoke at the seminar told us what they want in an LZ, how to conduct ourselves during the landing and after, and what we can do to the pt to assist them before they even land. They also mentioned that the bird could be used for ALS intercepts?! I couldnt believe it, they would actually fly out and drop off their medic to ride on an ambulance. Myself and most of my brothers and sisters agree we would never do that, unless there were a LARGE MCI somewhere and our resources were taxed to the max.

They also stated that "Stand-by's" are a waste of time. They are located, in our area anyway, on the roof of Albany Med, and in the town of Glenn just north of Schoharie County. Both locations have full crew quarters, so the "stan-by" notion is totally useless. He said if we need them, call them. We could always cancel the bird and send them home. (This way the pilot gets his/her hours in!!!) It only takes five minutes to fire up the bird and take off.

The class was extremely interesting and gave a lot of info on how to set up the LZ, I highly recommend you contact your local Life Net station and set one up for your counties.

As far as waiting for a bird to land, for more than 5-10 minutes?????

Our trauma centers are Albany Med (45 minute drive) which is level 1 I believe, and a level 3 trauma center in Bassett Hospital in Cooperstown about 30 minutes away over windy, back-mountain roads. If you can have the pt extricated and/or loaded in the rig relatively fast than you should be enroute to the hospital and either cancel the bird or meet them enroute at a differrent location. We have a back-up spot half-way between us and Albany located at the Duanesburg airport about 15-20 minutes away from us. Its a small private airstrip thats PERFECT for landing birds. So we arrange to meet them there instead of "waiting" on scene, that way if something happens we can atleast say that we were on our way to the hospital instead of "waiting for the bird to land". It takes 5 minutes to start it up and take off, 10-15 minutes to get to us depending on weather, and another 10-15 minutes to assess pt and render treatment, than 5 more to load and take off, than finally the 10-15 minute flight back. Thats 40 minutes (being nice by using the lesser numbers), in that time we could be arriving at the level 1 trauma center and getting the pt the rx they need before the bird even lands on the roof. THATS why I have mixed feelings about calling the bird.

I would only call it if I knew that I had an extensive extrication time. By then the bird will have landed and the medic could assist us with extrication and get the full report. I dont know, thats just my opinions and feelings.

Have a great day!!!

[WAS967 97]

I believe the standby idea came from the original STATFlight and how they were situated. STATFlight, when it was only Air1 located at the medical center, used their crew in the hospital (as hospital employees) for various things (I believe patient care related). When a call came in they would be paged and have to make their way to the bird before they could even fire it up. This generally took a few minutes, so we would put them on standby so they could rally before being given the order to launch.

[firemoose827 324]

I believe the standby idea came from the original STATFlight and how they were situated. STATFlight, when it was only Air1 located at the medical center, used their crew in the hospital (as hospital employees) for various things (I believe patient care related). When a call came in they would be paged and have to make their way to the bird before they could even fire it up. This generally took a few minutes, so we would put them on standby so they could rally before being given the order to launch.

←

Oh, ok, our birds have ft crews stationed on the top floor of Albany Med ready to respond.

[Guest]

Thats probably correct, i know a friend's wife used to be on the STAT team and if she wasn't on the chopper she was preforming hospital duty.

WAS those videos were awesome! I espesically like the second video with the actual drill. However, the disposable one is probably best for field use. I'm surprised that they actually did it on another doctor and he said it hurt less than some regular IV sticks, i was also surprised that it didnt leak/ooze post removal.

[STAT213 332]

Thats probably correct, i know a friend's wife used to be on the STAT team and if she wasn't on the chopper she was preforming hospital duty.

WAS those videos were awesome! I espesically like the second video with the actual drill. However, the disposable one is probably best for field use. I'm surprised that they actually did it on another doctor and he said it hurt less than some regular IV sticks, i was also surprised that it didnt leak/ooze post removal.

←

So, let me pipe in on a few of these things.

Standby. This whole concept was started for a number of reasons. Yes, the crew can be anywhere in the hospital so it can take time to assemble at the aircraft. While I was on the STAT Team, we didn't have assignments in the hospital per se, but could be asked to help out in any number of places. ED, IV starts, NICU, etc. There were times in the history of the team when they were assigned to be certain places at certain times. The other reason is so the pilot can check weather. But, if the crew was in quarters as described in Albany's situation it is not as important. Boston Med Flight doesn't do the whole standby thing at all. You either want them or you don't. I can see both sides, but everywhere I have worked in my 9 years of flying, we used the standby concept. Places where the a/c is stored inside, its a big help.

What the crew can offer...That depends on the program. Certainly RSI. The IO is another. (Don't you guys have this yet in NY?)

As for the whole snakebite thing. I did a few of those in my day at STAT. We had to beg to be able to land @ Jacobi. No one else had the antivenin.

As for safety. Someone mentioned that helicopters are dangerous. Why do you think this? Ambulances are spectacularly dangerous in design and practice. Granted when a helicopter crashes, it makes the news. Ever wonder why we don't hear about every ambulance crash? I would argue that its because there are just too many of them. If you want some good stats on crashes, check out www.emsnetwork.org and click on the crash section.

I do strongly agree that you should have LifeNet come do their PR/Class I used to teach them, and they are usually a good class.

[Oswegowind 17]

I knew that Jacobi was the only hospital in the area (maybe even the world) with almost every type of antivenom avail because of their proximity to the BXZoo, but I never did think about using the chopper to fly someone there from an outlying area! Great post, greater idea, patient will probly be happy to live even with the Helo bill!!!!!

[Guest]

Is there anything else on top of IO and RSI that air assets can offer? I was always under the impression that STAT had ALOT of treatment privileges. IE: what they could do w/o calling a doc. Probably just a misconception on my part.

[STAT213 332]

Is there anything else on top of IO and RSI that air assets can offer? I was always under the impression that STAT had ALOT of treatment privileges. IE: what they could do w/o calling a doc. Probably just a misconception on my part.

←

All tx in the a/c are standing orders based on protocol. Lots more drugs, and agressive pain management. Up here in NH, we are doing Chest Tubes, Central lines, surgical airways and giving blood to MS trauma patients.

Last I knew, STAT/LifeNet was not that aggressive. They might be doing central lines now, but we were not when I fled.

[Guest]

Damn! Talk about an ER with rotors! Do you see any dramatic differences or improvement in patient outcome?

[STAT213 332]

Damn! Talk about an ER with rotors! Do you see any dramatic differences or improvement in patient outcome?

←

In terms of what?

The evidence in the literature is quite clear that getting the patient to Level One services the quickest is worthwhile.

Its like asking if medics make a difference. Anecdotally, sure we do. Can you prove it? Nope. I like to think the things I did on the a/c made a difference, but we are learning new things everyday, especially coming from Iraq. Guess what's coming back - the tourniquet!!!

More later...gotta head out.

RA

[Guest partyrock]

Question for all you flyboys out there...why do air ambulances have such stringent flight restrictions? I've heard stat-flight grounded in conditions much better than white I've seen NYPD and other police agencies fly in. I've even seen new schoppers overhead on rainy days. Is this because of the variable condtion of the LZ's you might face or is just private companies and their associated sphincter pucker?