1. Aero-medical transfers Transfer Principles within the Rural Districts

2. Emergencies Training-Hospital Outreach and Support Airomedical transfer Objectives To examine the principles that apply when considering the mode of transfer To introduce the practical procedures necessary for effective preparation of an airomedical casevac To understand the basics of Safety around the aircraft on landing and take off To Know the steps needed for preparing a L.Z. for the Helicopter

3. Modes of transfer What should we be considering

4. Introduction The transfer is generally considered the most dangerous phase during the care of a critical transfer The benefits of airomedical transfers are obvious – reduced exposure to risk Cost assumes different importance when all aspects of the transfer are considered

5. Methods of Transportation Key aspects that must be considered: Triage Capacity Availability Evacuation and packaging Destination

6. Triage Triage category often dictates the manner in which patients are transported Red (unstable) patients are generally considered to be suitable for airomedical transfer However – assessment of triage tends to be inconsistent – impacts on use of Helicopters Growing realisation that even stable patients (yellow) may benefit from the use of helicopter transfer Cost effectiveness has been proven when all aspects of the transfer are considered – return trip, attendant, etc

7. Capacity Capacity of a resource very crucial in the decision to transfer a patient Fixed wing transfers have the advantage of being able to transfer several patients at a time Helicopters do have a few limitations though Even those that have been specifically designed for the E.M.S. environment have a tiny capacity to transport patients

8. Availability One of the key factors affecting the design of an EMS service in a particular area. The option of airomedical transfer offers several attractive options Central to this issue is keeping a critical resource in an area This should not be at any cost - (Remember the ambulance is there for the very reason that a critical patient may need to be transferred)

9. Evacuation and packaging This may prove challenging when preparing the patient for flight. Access to the patient and the ability to perform treatment interventions are severely compromised Catch 22 - Often packaging time is significantly greater when airomedical resource is utilised

10. Destination Not based on the particular triage category alone – definitive care critical Trauma patients prognosis improves with rapidity of transport Also avoids the strain that a later transfer may produce on an already overtaxed resource The goal must be to avoid secondary transfers

11. Non-emergency transfers An ambulance may not be necessary for all patients undergoing inter-facility transfer – HealthNET is a case in point. However certain conditions must be met SKYMED is thus not the only mode of transfer that ensures that an ambulance stays in a particular town. Considered thought is needed before dispatching a resource for this goal. Emergencies Training-Hospital Outreach and Support

12. Non-emergency transfers Conditions that must be met: The attendant or driver will not be expected to provide any medical attention medically stableThe patient is considered medically stable, and the act of transportation not expected to change the level of stability. part of the patient's lifestyleThe patient is not using any device (e.g., splint) or treatment modality (e.g., IV line) unless such a device is a part of the patient's lifestyle and he/she has been trained to care for the device.

13. Understanding the principles of patient care in the flight environment Aero-medical transfers

14. Emergencies Training-Hospital Outreach and Support Airomedical transfer Airomedical evacuation is safe for transporting almost any patient, But … The Following conditions must be met:  Well-prepared, well-trained medical escort/team  Medical equipment that is qualified as “safe for use”  A therapeutic dose of pessimism

15. Emergencies Training-Hospital Outreach and Support Airomedical Information The attending physician – determine destination, urgency, and mode of transport Discuss additional steps to further stabilize the patient An appropriate SAMPLE history The results of diagnostic tests Any special equipment requirements Any problems anticipated

16. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Pre-flight stabilization  Critical aspect of any transfer   Avoid ‘scoop and run’ – note exceptions  Immobilise all patients securely and comfortably – spinal cord injuries  Feng shui of aeromedicine – plan the packaging of you patients and equipment  Gather as much info from the facility staff

17. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Management Airway Adequately asses the respiratory status Anticipate problems which may arise during transfer FiO2 requirements increase with altitude Breathing Respiratory emergencies must be managed prior to transfer eg. pneumothorax, flail chest Prophylactic chest drains may be needed No Glass drainage bottles

18. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Management Circulation Maintaining adequate IV access is critical. Make sure all IV tubes and other attached lines are secured well. Consider saline locks for IV lines that are not needed for volume replacement Again - no glass bottles

19. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Management Disability Neurological status must be assessed before and during transport. The Glasgow Coma Scale is a useful tool for such assessments. Note the time. This may need to be managed in consultation with the receiving physician.

20. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Management Exposure Ensure patient is comfortable – beware hypothermia When packaging ensure access for treatment and examination Consider inserting a nasogastric or orogastric tube. Consider inserting a urinary catheter Remember the escorts

21. Emergencies Training-Hospital Outreach and Support The aeromedical transfer Preparation – patients/escorts  Arrange for an appropriate escort(s) to accompany the patient.  The safety of the patient and the escort(s) during transport must be a priority at all times.  Prepare the patient and escort(s) for transport  Secure all passengers, equipment and supplies within the aircraft  Ensure all passengers are familiar with safety procedures and emergency exits.

22. Emergencies Training-Hospital Outreach and Support The aeromedical transfer The Receiving physician Before the transport begins: –When possible, contact the receiving physician and healthcare facility –Ensure that they can accept the client –Discuss the relevant clinical information - ensure that all relevant documentation accompanies the patient – X-rays, notes, results –Discuss additional steps that can be taken to further stabilize the client

23. Setting up a landing zone Helicopters and LZs

24. Preparing an LZ Touchdown area should not have more than a 1-2 degree slope. Landing and take-off area should accommodate heli wingspan- min 25m diametre. Should have no tall structures within 50m. Emergency Care-Hospital Outreach and Support

25. Preparing an LZ Is the LZ in an area where people normally walk? Is the LZ close to the hospital, so that someone can watch and protect it from theft and vandalism? Is there a windsock available close to the LZ to guide the pilot w.r.t. wind direction?

26. Emergency Care-Hospital Outreach and Support Preparing an LZ If it is on grass and has an underground sprinkler system, at what times is it activated. Do the prevailing winds channel around buildings, which may catch the pilot by surprise? Is the LZ accessible to hospital staff, with a trolley?

27. Emergency Care-Hospital Outreach and Support Preparing an LZ It should be asphalt, grass or hard-packed dirt, but not sand. Ensure that the area doesn’t get muddy when it rains. The trolley must run freely. Ensure that the area is free of rocks, stumps, pegs, garbage and other debris

28. How not to lose your head Safety around helicopters

29. Emergency Care-Hospital Outreach and Support Helicopter Safety Do not load/unload while the rotor blades are turning. Do not approach a helicopter with the blades turning, without permission. Do not walk around the tail of the heli without permission. Do not approach a helicopter from an uphill. Do not smoke around a helicopter, ie. Fuel and 02

30. Emergency Care-Hospital Outreach and Support Helicopter Safety Do not carry long items like drip stands, splints or an extended arm above your head. Do not wear a hat when approaching a chopper. Do not use barrier reflective tape to cordon of the landing area. It will blow into the rotor. Do not run out to meet the chopper when it is landing.

31. Emergency Care-Hospital Outreach and Support Please.. Keep all personnel inside the hosp and away from the landing area, until the rotors have stopped turning. Request the pilots permission, before approaching the helicopter. Approach the chopper from the front….always.

32. Emergency Care-Hospital Outreach and Support Please.. Control bystanders and animals away from the landing area. Dogs ears are sensitive to the high-pitched noise, and they tend to want to bite the tail rotor. Approach chopper from below if it is on a slope. Stop all vehicles that may pass through the landing area… completely.

33. Emergency Care-Hospital Outreach and Support Please.. Secure loose articles, to prevent them from lifting into the rotors. Check the landing area for any loose debri, before the choppers arrival. Have a C02 fire extinguisher at hand, and know how to use it.

34. Emergency Care-Hospital Outreach and Support Please.. Have a trolley ready, with NO mattress, NO sheets and NO drip stands, and only approach when signalled to, when the rotors have stopped turning.

35. Emergency Care-Hospital Outreach and Support Summary We have just looked at: The principles that determine mode of transfer The aspects that influence the care of a patient in flight The basics of Safety around the aircraft on landing and take off The steps needed for preparing a L.Z. for the Helicopter

36. Questions End