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Zachary T. Fica MD, MS; Amy Marquez MSN, CFRN; John Ehrhart FPC; Christian Sloane MD

Abstract

We present the case of a 10-year-old previously healthy male who suffered an out-of-hospital cardiac arrest because of abdominal trauma and survived with excellent neurologic outcomes and near complete return to baseline functional status at hospital discharge. The rapid response and efficient mobilization of resources led to an excellent patient outcome despite the severity of injuries, including intra-abdominal injuries with expected mortality, out-of-hospital traumatic arrest, coagulopathy, and an extended pediatric intensive care unit stay. This case underscores the significance of timely advanced trauma life support interventions, especially early blood product administration, efficient transport, and airway management, while sharing a remarkable case of out-of-hospital pediatric traumatic arrest with near full recovery.

A 10-year-old previously healthy male called his mother on his smartwatch saying he had crashed his bicycle while riding in their neighborhood and felt unwell. His mother called 911 who activated emergency medical services, and the local advanced life support fire department arrived at the scene to find the patient pale and lethargic with right-sided abdominal pain. Recognizing the need for immediate transport to the nearest pediatric trauma facility approximately 35 miles away, helicopter emergency medical services (HEMS) was requested per county protocol because of a shorter transport time.

Click below to read the full case report and discussion published by ScienceDirect.

David J. Olvera MBA, NRP, FP-C, CMTE; Michael Lauria MD, NRP, FP-C; Jeremy Norman BAS, NRP, FP-C; David Gothard MS; Andrew D. Gothard BS; William Bradley Weir MD, FACEP, FAEMS, FAMPA

Abstract

Objective

Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit.

Methods

This institutional review board–approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist.

Results

Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation.

Conclusion

The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Click below to read the full research paper published by ScienceDirect.

When an infant patient faces seemingly insurmountable odds over the course of several hours, one of our clinicians suffers a mental health breakdown over the ensuing shifts, days and weeks. Thankfully her team recognized changes in her behavior and mood and offered abundant help. This episode covers not only the case involving the infant patient, but the aftermath and care for our clinicians. If you, or someone you work with, is struggling with your mental health, please reach out to Shatterproof, part of FHE Health on the web or at (833) 591-1536.

Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits. 

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-37-asking-for-help-isnt-giving-up. To join the conversation, use the hashtag #AMPEDpod on social media. 

Our profession requires extensive and exhaustive training. Much of it can seem esoteric and possibly unnecessary at the time, but we train on all of these things for a reason. When our team comes upon a severely burned patient, they extent of the burns causes a melange of difficulties. Could an obscure, and rarely used, procedure ultimately help and provide the patient more time? The AMPED team discusses this little-used technique and we discuss the importance of remaining familiar with the abundance of techniques and treatments we learn during our training.

Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits.

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-36-sometimes-the-solution-is-obscure. To join the conversation, use the hashtag #AMPEDpod on social media. 

As first responders, the odds of patient survival are not always in our favor. But that does not stop us from working quickly to provide the highest level of care for the chances of defying those odds. In this episode, a 10 year-old boy wrecks on his bicycle, a fairly common occurrence and one that rarely requires air transport, yet when our team arrives on scene, his vitals crash in front of their very eyes. What’s going on? And what actions do they take to save his life? An inspirational, harrowing and odds-defying episode of AMPED awaits you this holiday season.

Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits.

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-35-hope-is-a-good-thing. To join the conversation, use the hashtag #AMPEDpod on social media. 

February is American Heart Month, a month dedicated to promoting heart health and recommitting to our cardiovascular wellbeing. We also acknowledge pivotal programs like Mission: Lifeline®, a national American Heart Association initiative. Their goal is to revolutionize the system of care for patients facing critical heart-related emergencies. Mission: Lifeline® unites healthcare professionals and stakeholders to significantly raise survival rates and improve the quality of care for patients being treated for cardiac events. Their recognition system is well known throughout the country and celebrates hospitals and EMS agencies that consistently excel in timely, evidence-based care for acute heart conditions.

“Mission: Lifeline® gives us a roadmap best practices to deliver the best possible patient outcomes of STEMI and Stroke care.  Air Methods provides our hospital and EMS partners a means to provide rapid and highly acute patient transport in order for them to obtain Bronze, Silver and even Gold recognition.” said Air Methods VP of Clinical Services, Kelly Miller.

At Air Methods, we are proud to play a key role in this life-saving initiative by providing indispensable support through:

“Time equals muscle for our STEMI patients and brain for our Stroke patients,” Kelly explains. “Air medical transport, when activated early, will improve patient outcomes and save lives.”

Air Methods is dedicated to assisting EMS and hospital personnel in delivering the highest standard of patient care possible. Our air medical services directly impact the AHAEMS8, AHACAD9, and AHACAD23 recognition criteria across EMS, Receiving Center, and Referring Hospital programs. View the criteria here. If you are interested in partnering with Air Methods to increase quality of care and potentially receive Mission: Lifeline® recognition, click here and your local Air Methods representative will get in touch.

Concepts, research, and solutions pertaining to this article were contributed to by Aidan O’Connor, NR-P, FP-C, Regional Sales Director at Air Methods, and William Kelly Miller, Vice President of Clinical Services at Air Methods.

Air medical transport has been facing challenges in recent years, with a few emerging trends currently at the forefront. We are seeing changes in the industry emerge, from staffing shortages and increased specialty transports, to feeling the effects of the No Surprises Act. As we approach the end of 2023, we want to share the top three trends that we have observed here at Air Methods. 

1. Staffing Shortages

The industry, including medical transportation and healthcare facilities, is being heavily impacted by staff shortages affecting roles such as pilots, healthcare workers, and maintenance technicians. The presence of skilled personnel is crucial for providing high-quality care. However, it’s not just the medical transportation industry that’s grappling with these challenges. Hospitals and health centers are also struggling to maintain adequate staffing levels. Many rural communities are facing the decision of closing beds or units due to insufficient staffing. In some cases, specialty services like Labor and Delivery are being cut back. These shortages are placing enormous pressure on local ground transport and air services to ensure patients receive the necessary level of care. 

Key insights into the reasons behind staff shortages: 

A critical factor behind the shortage of medical professionals in the air medical industry is the high demand for their services. As the population grows older and medical emergencies become more frequent, the need for skilled practitioners and pilots in air transportation is rising. Becoming a qualified medical professional in this field requires rigorous training and extensive financial investment, which can put off some individuals from pursuing careers in healthcare. Furthermore, the competitive job market for healthcare and aviation sectors makes it challenging for the air medical industry to attract and retain top talent. 
 
Meeting strict safety and regulatory requirements also presents challenges for professionals working in air medical transport. The aviation and healthcare industries are both highly regulated to ensure the safety of patients and crew. This demonstrates the need for constant training and certification in addition to experience, which adds even more pressure to an already high-stress environment. Workload and stress are other significant factors associated with the air medical shortage crisis. Air medical professionals frequently face demanding work schedules and high-stress situations, which can lead to burnout and affect employee retention rates. 
 
Overall, these challenges contribute to a shortage of medical professionals in the air medical industry, a crucial component in transporting critically ill or injured patients quickly and efficiently. 
 
Read more about pilot staffing shortages here. Read more about clinical staff shortages here. Read more about AMT staff shortages here

2. Increasing Demand for Specialty Transport

Specialized transport is on the rise, particularly in the fields of pediatrics and cardiovascular care. This includes transporting pediatric patients and newborns in the neonatal intensive care unit (NICU). We have also seen an increase in cardiovascular assist device transports for patients that require specialized interventions like IABP (intra-aortic balloon pump), Impella and ECMO (extracorporeal membrane oxygenation).  

Key insights into reasons for increase in specialty transport: 

The number of patients being transported by air has grown in recent years due to several factors. One of them is the regionalization of care as healthcare systems concentrate specialized services in specific hospitals. This often means that patients need to be transported from one facility to another, and air transport is crucial for ensuring they have access to these specialized centers. In addition, advances in neonatal and pediatric care have expanded the range of conditions that can be successfully treated in pediatric patients, making air transport an even more viable option for critically ill children. 

Another factor driving the increase in air medical transport for patients is the growing awareness and utilization of this service. Healthcare providers, emergency medical services, and the public are becoming more aware of the benefits of air medical transport. Increased awareness and utilization of air transport services can provide a critical link in the chain of care, helping ensure that patients receive the specialized care they need in a timely manner. 

Population growth is also contributing to the rise in air transport. With more and more people living in urban areas, traffic congestion on the ground is often a factor that can hinder the safe transport of critically ill patients. This increases the need for air transport, which can bypass ground traffic and quickly bring patients to the medical facility they need. 

Read more about the increase in pediatric specialty transport here. Read more about the increase in cardiovascular specialty transports here.  

3. The No Surprises Act’s Impact on Medical Transport  

The No Surprises Act went into effect in 2022 for the air medical industry. This is a law that Air Methods strongly supports as it removes patients from the middle of any billing dispute between medical providers and insurers, thereby protecting patients from “balance bills.” Now, when an out-of-network insurance company refuses to cover or under-reimburses for an emergency air transport of one of its customers, the air medical provider and insurer can enter an independent dispute resolution (IDR) process to resolve the billing dispute. This new system eliminates the possibility that a patient could receive a bill for unpaid transport. Unfortunately, the IDR process has been structured to favor insurance companies rather than air providers, particularly those in rural areas, and these remaining out of network health plans have pursued tactics of delaying payment or underpaying for critical services. While Air Methods has been a leader in the industry going in network and today is 76% percent in network with health plans, we have had to pursue the IDR process for the remaining out-of-network transports. We win these cases 87% of the time but it has delayed payments by months. States are looking at similar NSA-style initiatives for ground transportation, which may result in similar cost pressures for ground transport. We will have to wait and see if these changes result in loss of access to ground transport for patients leading to further demand on the air transport industry to fill the gap left by ground transportation, especially in rural America. 

Read more about the No Surprises Act and its impacts here.  

Things are not as they seem on this month’s episode of AMPED. Our team arrives on scene to find first responders dealing with a chemical burn and administering CPR. But something is amiss. This episode is a stark reminder that no matter the time of day, no matter the other circumstances, our role as clinicians is to stay vigilant in our analysis and always to assess every aspect of the situation thoroughly. We are joined by Amy Merritt, BSN RN CFRN, and Allen Walworth NREMT-P.

Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits.

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-34-dont-be-a-canary. To join the conversation, use the hashtag #AMPEDpod on social media. 

Our goal at Air Methods is to provide the highest level of emergency medical services to our patients, and the cornerstone of achieving this goal is a highly trained pilot. The need for continual pilot training and simulation is essential in the aviation industry for safety, accuracy, and compliance. While training on an aircraft is necessary, practicing in a level D simulator is advantageous for our pilots. We’ll explore the advantages of training in simulators and why it’s so critical. 

About Level D Simulators  

In 2015, we began leasing level D simulators from FlightSafety International, a company that offers extensive, full-flight simulators used for training commercial, government, and military organizations. Air Methods employs in-house instructors to conduct pilot training on these 15-million-dollar simulators. Air Methods pilots currently train in them across nearly all major airframes in the fleet. 

Level D simulators are the gold standard of flight training because they provide a realistic training environment. Our pilots get the closest experience to actual flying in the simulator and it’s the only non-aircraft training method accepted by the FAA.  

Advantages of Simulator Training  

There are several advantages for pilots when training in a level D simulator. For starters, pilots can train dangerous scenarios like engine failures and loss of tail rotor thrust without risking lives. They can also train better for emergencies and incidents by repeating certain scenarios and stopping to talk, evaluate, and retrain until they can accomplish them correctly. Using a simulator allows pilots to reset scenarios quickly, providing effective training in less time. An added benefit of utilizing a simulator also means that no air base is taken out of service for training exercises. For Air Methods pilots, most training is now done in a simulator which is also the same standard for commercial airlines.  

“Level D simulators are an especially great training tool to get comfortable with the aircraft instruments for pilots transitioning from fixed wing aircraft to rotor wing and for pilots transitioning to a new aircraft model.”  -LifeNet Pilot Shawn Miller 

What Is Involved in Simulator Training 

Employee simulator training is a significant part of Air Methods’ training requirements. Before pilots can be hired as a HEMS (Helicopter EMS) pilot, they must have logged at least 2000 hours of flight time. This standard is set high to ensure that each Air Methods pilot is not only capable of doing their job, but capable of going above and beyond to provide the highest level of care. In fact, our requirement exceeds the FAA standard by eight hours in the simulator.  

Simulator training involves one to two recurring training events per year for current Air Methods pilots, each lasting three to five hours. Additionally, simulators are used to train maintenance personnel. 

Applying Specific Scenarios During Drills  

In single-engine, VFR helicopters, simulators are crucial for effectively practicing flights where cloud cover is present. Typically, when training without a simulator, pilots will use eye covers for this specific drill which isn’t as effective. But in a simulator, pilots repeatedly practice these challenging scenarios. Since incorporating simulators for practicing a drill in a single-engine, VFR scenarios, no crashes have occurred in this scenario at an Air Methods base. 

During reoccurring annual training, an experienced pilot in Arizona requested additional practice with engine failure and emergency landing scenarios. Less than a month later, the pilot encountered an engine failure incident in the field and successfully performed an emergency landing without any additional damage to the helicopter or its crew. 

What’s Coming Next  

In 2024, a new initiative called “Mission Training” will be implemented for each new hire. Previously, pilots were trained individually on specific aircraft and scenarios. However, with scenario-based immersion training, trainees will go through the entire process of an actual flight, including working with the team and conducting safety risk assessments. This comprehensive training aims to provide a clearer understanding of the day-to-day responsibilities of an EMS pilot, resulting in better preparedness for new pilots. 

Air Methods strives to achieve the highest level of safety, professionalism, and care for each of its patients. Training our pilots using Level D simulators from FlightSafety International is efficient and provides a realistic training environment. It allows us to train and equip the best pilots the industry has to offer. Moving forward, we’ll continue to focus on employee simulator training, and driving the industry forward with the best EMS experience to patients.  

In a Florida nature park, a woman is bitten by a snake, which is not terribly uncommon in this part of the country. What is unusual is her reaction to it, which is severely anaphylactic. With limited resources in the sprawling park, a closing window for treatment, and critical decisions to be made instantly, how will the team assess, handle and treat our patient in this week’s episode? And why such a severe reaction? Find out when you tune in. We are joined by Thomas Young, NPFR FF/PM EMS FTO, Matthew Johnson RN, Flight Paramedic FSR, FP-C, D​MT, NREMT-P, & Joshua Webster Flight Paramedic FSR, FP-C, D​MT, NREMT-P.


Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits.

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-33-look-one-way-but-go-another. To join the conversation, use the hashtag #AMPEDpod on social media. 

Our teams at Air Methods have many checklists they follow to ensure optimal care for each patient. What happens when our teams have to pivot their approach and their treatments because of the uniqueness of each individual? On this episode, our team tends to a car crash victim whose injuries make traditional methods of care impossible, and the team is forced to pivot multiple times to provide treatment. This episode also tackles the question of when it’s appropriate to give the patient’s family the gift of a goodbye. We are joined by Jacqlyn Murray FPC NREMTP, and Teresa Click BSN, RN, EMTP, CEN.

Interested in obtaining CE credit for this episode? Visit OnlineAscend.com to learn more. Listeners can purchase individual episode credits or subscribe to the Critical Care Review Bundle and gain access to all episode CE Credits. 

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-32-giving-the-gift-of-goodbye. To join the conversation, use the hashtag #AMPEDpod on social media.

Hot on the heels of Ep. 31, which featured the Air Methods team taking care of one of their own, we return with bonus content. It’s rare that we get to talk to the patient of one of our cases, and even rarer that the patient is also one of our clinicians. In this bonus interview, we share more of our conversation with Jeff Chesleigh as he divulges what it was like to code multiple times, his thought process during the ordeal, how his approach to patients going through a similar experience has changed, and the aftermath of the event. The conversation is riveting and informative.

AMPED is available on Apple Podcast, Spotify, Google Podcasts, Stitcher, and more. To listen to the episode or catch up on past discussions, visit https://ampedpodcast.libsyn.com/air-methods-prehospital-education-podcast-ep-315-when-it-hits-close-to-home-bonus-interview. To join the conversation, use the hashtag #AMPEDpod on social media.