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September 2014

Objectives

History of Pre Hospital Provider

History of Ambulance Service

History of Air Medical Transport

The Modern Day Ambulance

Safety and Medical Transport

Why Fly / Capabilities / Resources

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Roots of Para Medicine

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

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

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

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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

Moving injured soldiers from the battlefield: Civil War

City Ambulance circa 1890

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.

World War I Troop Ambulance

1948 Cadillac A. J. Miller hearse modified into an ambulance

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.

A 1973 Cadillac Miller – Meteor ambulance. A higher roof, with more room for attendant and patient

The modern day ambulance comes in many shapes and sizesConvalescent to Critical & Specialty Care

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Air Medical Transport in the begining

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

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.

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

Curtiss JN – 4D “Jenny” circa 1918

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

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

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

H1- “Huey” Vietnam circa 1970

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

Modern day helicopter ambulance also comes in many differentshapes and sizes

Thank you Roy Morgan

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

Flight for Life original crew circa 1972

The modern day medical transport team

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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

Recent statistics

Calendar Year 200319 Accidents7 Fatalities

Calendar Year 200413 Accidents18 Fatalities

Calendar Year 200515 Accidents11 Fatalities

In the 11 month period between December 2007 – October 20089 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 200613 Accidents5 Fatalities

Calendar Year 200711 Accidents7 Fatalities

Calendar Year 200813 Accidents29 Fatalities

Recent Statistics

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

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

Flight Safety Tools and Procedures

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

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FLY Trauma? Critical Care? Specialized care to patient bedside? Need to move?

The modern day ambulance interior

Ambulances are mini ICU’s and Emergency Departments

Time Sensitive

Trauma

STEMI

Stroke

Vascular Emergencies

Specialty Care Teams› Peds / Neo› Physicians – Donor services› Perfusionists

Critical Care

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

Distance / Environment

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

Medical Control

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

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Request for Service

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

Request for Service

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?

Multiple Services Available

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

19 Hospital Affiliated aircraft – 1 EMS – 1 Military

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

Fly Safe