The Aeromedical Concept

Skilled Medevac Teams Use Advanced Medical Techniques To Save Lives

Copyright 1987, The Pittsburgh Press Co.

By Andrew Schneider

Wetzel County (WV) firefighters carry the critically-injured victim of a truck collision toward the landing zone where an aeromedical helicopter awaits.

Death by t rauma or heart attack often can be prevented by surprisingly simple medical techniques quickly done. These lifesaving interventions are preformed daily in almost every major city by flight teams staffing the nation's 442 medical evacuation helicopters.

The Korean War proved that rapid helicopter transportation of the wounded to tent hospitals could save lives. Vietnam showed that the addition of well-trained medics who began treating the injured enroute increased their chance of survival.

Today even more advanced techniques are being used by pilots, flight nurses, paramedics and doctors at 231 hospital-based and government medevac programs. Doctors say many of the more than 550,000 patients transported by air ambulance in the last 17 years are alive because of it.

"Trauma patients are usually saved in one or two places," says Dr. Hank Bock, medical director of ASHBEAMS, the professional association that represents most of the nation's medevac programs. "It

can be at the scene with some relatively simple procedures like clearing an airway so they can breathe, or starting blood to prevent shock.

"The other way they help is to quickly get these patients to a major t rauma center, with surgeons waiting and ready to start operating to repair the problem. The helicopter and its team can do both, and that 's why they save the lives they do." It was that type of effort that saved the life of Paul Bartmas on Oct. 1.

The sun was just rising as Bartmas drove his bakery truck through the Pittsburgh suburb of Pleasant Hills. Then came the collision with the steel edge of the rear of a flatbed trailer filled with pumpkins.

The impact imprisoned Bartmas in a mass of jagged metal. Seconds later rescue units from three communities and a nearby hospital began converging on a scene littered with shattered pumpkins, torn steel and blood.

Within minutes, the call went out for more help, and rotors began

spinning on a medical evacuation helicopter at Allegheny General Hospital. Seven minutes after liftoff, another team of medical specialists was at the side of the 33-year-old truck driver.

Roadside teamwork kept Paul Bartmas alive; medevac gave him a chance to recover.

Before Life Flight I landed at the scene, emergency medical technicians and paramedics began feeding lactated Ringer's solution through two intravenous lines into one of Bartmas' arms. Ringer's is often used by paramedics on trauma patients because it can temporarily inhibit fatal shock from blood loss. But while the liquid's chemical composition is similar to blood, it cannot carry oxygen through the system. Without oxygen, brain damage, cardiac arrest and death are inevitable.

A rapidly spreading pool of blood under the truck and Bartmas' plummeting blood pressure told flight nurses Susan Randall and Andy Barrett that the man had massive, bleeding injuries to his lower body which was concealed by

10 HOSPITAL AVIATION, JANUARY 1988

The Aeromedical Concept

the wreckage. Ringer's alone would not sustain the man's life.

Squeezing between rescue workers attempting to cut the metal away to free Bartmas, the nurses replaced the Ringer's solution with plastic bags of O-negative blood, a staple on t rauma flights. O-negative is considered the universal donor blood, and can be given to almost everyone without adverse reaction.

During the 90 minutes it took to cut and pry Bartmas free, Life Flight's nurses used their three units of blood and another three rushed in from a nearby hospital.

The flight back to Allegheny General took only four minutes. Eighteen minutes after that, t rauma surgeons had Bartmas in operating room No. 5 and were beginning five hours of surgery.

"He was dearly in shock when they wheeled him in," said Dr. John Raves, the t rauma surgeon who led the team. "His right leg had been amputated below the knee, he had major fractures and massive internal injuries.

"He's gotten more than 30 units of blood in the past 17 hours, but without that blood he got in the field and the work done by paramedics and flight nurses, he never would have made it to the OR alive.

"It's another case that shows good medics teamed up with a helicopter's medical team can make all the difference in the world."

Bartmas was one of more than 400 people treated and transported that fall day by medevac programs in every state but four.

These airborne medical teams do many things, but paramount in all they do is the basic lifesaving doctrine of keeping a patient breathing, out of shock and from bleeding to death.

A Pittsburgh Press survey of all the nation's helicopter programs found that 86 percent of the medevacs fly with registered flight nurses and paramedics, and most are cross-trained in a wide variety of rescue skills, advanced cardiac and trauma lifesaving techniques and intensive care procedures. Because of this intensive training, most state

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The Aeromedical Concept

medical practice boards usually permit flight teams to perform procedures far more sophisticated than those normally undertaken by their colleagues in emergency rooms and ambulances.

In Pittsburgh and several other medevac programs around the nation, flight medical teams are trained and authorized to perform several advanced techniques in the field and in the air. These can include simple things such as a cricothyrotomy (inserting a tube or needle into the trachea or windpipe to allow a person who is choking or has an obstructed upper airway to breathe) to a more complicated escharotomy (surgically removing the skin of a serious burn patient to prevent edema, or swelling, of the burned tissue from cutting off circulation to the limbs or compressing the chest to the point where the heart stops).

Learning techniques is the easy part, says Denise Ramponi, supervisor of flight nurses at Pittsburgh's Life Flight. "Knowing when to do them, and how to do them instantly, demands a lot of study. These invasive skills can and do save lives, but you've got to be ready to do it and do it right."

The skills are not theoretical. They are used in streets and fields around the country, and they have saved lives. Paul Bartmas' accident on Pennsylvania's Route 51 was just one episode. There are many others.

Late in July, five people were injured in an afternoon rush-hour collision in the South Hills, eight miles from Downtown Pittsburgh. Local paramedics were doing a good job handling four of the injured. The fifth, a 25-year-old man, was removed from the wreckage with severe head and chest injuries. His heart stopped just as Life Flight I landed on Route 19.

Within six minutes, flight nurses Karen Paig and Frank Kislan intubated the man, forcing air into his lungs; they inserted a long needle through the ribs in his upper chest to release a mass of air that was forcing his collapsed lungs against his heart and preventing it

from beating; they injected a variety of cardiac drugs to jar the dormant heart back to life.

Five minutes after taking off from the highway, the crew had the man in Allegheny General and under treatment by the full t rauma team. He survived.

It was a little after noon on Aug. 20 when a 7-year-old boy was knocked off his bike and run over by a car in East Liverpool, Ohio.

Angel I was dispatched from its base at Pittsburgh's Mercy Hospital, and 20 minutes later, in East Liverpool Hospital, Angel's medical team, flight nurse James Holland and Dr. Jim Melton, worked with the emergency room team to stabilize the boy and prepare him for transport.

But two minutes after Angel I lifted offfor the 41-mile flight back to Pittsburgh's Children's Hospital, there was trouble. A green screen on a pulseoximeter, a new device that continuously monitors the amount of oxygen in the patient's blood, flashed a warning: "low perfusion." The child's blood pressure had dropped to a point that would not sustain life.

While Holland attached plastic bags of whole blood to tubes that had been running clear intravenous fluid into the boy's arms, Melton started another line on the boy and hung a third unit of blood from a hook on the ceiling of the helicopter.

Children's t rauma team was waiting at the pad and the boy arrived alive.

"There isn't any question that the outcome would have been different if fluids weren't administered rapidly and in volume by the helicopter team. The child needed blood badly. He was bleeding severely from a ruptured spleen and losing still more (blood) from head wounds. Without the blood he wouldn't have had a chance," said Dr. Don Nakayama, co-director of Children's Hospital's t rauma center.

Intervention of these medical teams is not only vital at an accident scene, but often proves crucial on the more routine hospital-to- hospital transfers, which compose

the almost 80 percent of the nation's medevac flights.

Angel I was making such a transfer of a 30-year-old heart attack victim last month from Uniontown to the cardiac catheterization lab 50 miles away at Pittsburgh's Mercy Hospital. The young man was in stable condition, not in much pain and even joking with the crew. But as flight nurse Holland and Dr. John Reed loaded him into the aircraft, his heart stopped.

The routine became critical. For the next 10 minutes, working

inside the helicopter, Holland and Reed fought to restart the young man's heart. Cardiac drugs and electric shock got the heart pumping. But a moment later it stopped again. The resuscitation started and they brought him back to life. Mercy's heart team was waiting as Angel I landed on the hospital's mushroom-shaped helipad.

"The medical team not only saved his life but their fast action prevented (heart) damage which could have affected the patient's productivity for the rest of his life. It clearly was a case that proved the cost-effectiveness of the helicopter," said Dr. Verne Shaver, senior cardiologist at Mercy who treated the victim.

The young man left the hospital for home three days after his dramatic arrival.

Not all medevac missions have successful endings, however.

It was 5:20 on the afternoon of Aug. 3 and the crew of Pittsburgh's Life Flight I was only 40 minutes from getting off work.

Two sharp tones shrilled from beepers on the belts of the flight nurses and the brick-sized radios that are always carried by medevac pilots on duty at Allegheny General.

"Flight page. Flight page. Life Flight I. Team One. Scene run. Wetzel County, West Virginia. Motor vehicle accident," squawked the crew's electronic tethers.

Coffee cups were put down, medical charts slammed shut and the nurses and pilot headed for the helipad, stopping only long enough

HOSPITAL AVIATION, JANUARY 1988 13

The Aeromedical Concept

to pull four units of Type O blood out of a refrigerator and cram it into a small ice chest.

Life Flight's lead pilot, John Johnston, already had checked weather and was almost finished doing the quick but thorough walk-around inspection of the burgundy-and-gray BK- 117 helicopter.

Flight nurses Lucy Klimko and Patrick Wertz secured their seat belts and shoulder harnesses, and over the ship's intercom told Johnston, "We're ready in the back."

With almost automatic moves Johnston fed fuel to the two 650-horsepower engines, pulled up on the controls and at 5:25 the 6,223-pound helicopter was airborne.

Climbing to 2,000 feet he passed over the towering steel and glass of downtown Pittsburgh and the bumper-to-bumper traffic clogging its bridges and parkways and turned the aircraft westward.

"Departure control. This is Life Flight I. Off from AGH. Heading southwest at 2,000 feet," Johnston told air traffic controllers at Greater Pitt where a flashing symbol indicating his aircraft's position and altitude suddenly appeared on their radar screens.

Back at Life Flight's control center, dispatcher Carla Klym took the meager information on the accident's location supplied by medics at the scene. Working on a wail-size map, she translated it into navigational headings that would get Johnston into the general area.

"Life Flight I, this is control," Ms. Klym radioed. "We still have no information on your patient. Radio communication from the area is very bad. Your destination is Pine Grove in Wetzel County. Your RNAVs (radio navigation headings) are off 110, 52 nautical miles. 220 degrees. 151.26.2 nautical miles. 230 degrees. Do you copy?"

The information was expected to get Johnston close to the accident scene, but in the repetitious mountains of West Virginia, close is not always good enough.

While the weather was clear and

bright in Pittsburgh, by the time Life Flight I hit the West Virginia state line isolated pockets of haze had merged into a solid blanket and the green hills ahead could only be distinguished by varying shades of gray. A good tail wind pushed the helicopter along at 150 mph through intermittent swirls of low clouds that briefly surrounded the aircraft.

"The (weather) forecast gave us no clue that this was out here because there's no observation stations out here. So we're on our own," Johnston said. "Life Flight I, position report, please," requested Ms. Klym, and Johnston replied with coordinates of his location.

frequency used by most ambulance units.

"Wetzel County Ambulance, this is Life Flight I. We should be somewhere over you now," Johnston radioed.

"We can hear you, Life Flight, but we can't see you. Look for a road running east and west and we should be right at the big curve," Wetzel radioed back. "This man's going sour on us. We need you here soon."

From 2,000 feet Johnston could see at least three roads running east and west through the haze-shrouded hills.

"We see you now Life Flight.

Life Flight I (Allegheny General Hospital, Pittsburgh, PA) crewmembers and volunteer firefighters transfer accident victim to helicopter stretcher.

(At Life Flight, and many other programs throughout the country, the aircraft's location is broadcast every 15 minutes while the helicopter is airborne. Scott Dieterich, Life Flight operations manager, says flight following is a precaution that provides a point to start searching if an aircraft is missing.)

In 22 minutes they were 72 miles from Pittsburgh and within a mile of the accident.

"Navigational aids are great but they can go out anytime and a pilot had better know where he is," Johnston said, waving a navigational chart. Then he tried to contact the ground units on 155.340, the radio

Turn left. Turn left," the radio crackled. "The landing zone should be right below you."

Johnston pulled the aircraft into a tight, slow turn and the BK-117 shuddered as he reduced power. Below, about three dozen people were crowded around the twisted steel of what was once a truck. In a field across a creek, eight flrefighters in bright yellow turnout coats marked the makeshift landing zone.

"Watch out for the wires," they radioed from the ground.

"You bet I will," Johnston muttered as he slowly eased the helicopter into a hover above the small field of freshly cut grain.

''You've got wires to your left,"

14 HOSPITAL AVIATION, JANUARY 1988

The Aeromedical Concept

Wertz reported. "Also to your right and behind,"

Ms. Klimko added. "I've got them in sight." Johnston

said as the helicopter gently settled into the soggy field at 5:56 p.m.

Wertz told Johnson the patient sounded too critical to waste any time and asked if the crew could "unload hot" - keeping the engine running and rotor turning. Johnston approved.

Their arms filled with bandages, medication and intravenous fluids, Ms. Klimko and Wertz instinctively ducked under the blades spinning four feet above their heads and raced 100 yards up the road where the medics were clustered around a bandaged-swathed man.

Flight nurses Patrick Wertz and Lucy Klimko work to save a life 2,000 feet above West Virginia forests.

As they listened to the medics' report, the flight nurses quickly assessed the man's condition. He was having a hard time breathing; his pulse almost too weak to detect.

"Let's get him out of here," Wertz said. Ms. Klimko nodded agreement and raced back to the helicopter.

Johnston was already pulling the litter out of the helicopter and toward the approaching group of six firefighters who were carrying the 52-year-old man.

Only eight minutes were spent on the ground, and at 6:04, Life Flight I lifted off.

There was little conversation in the cabin. Both nurses were busy. The man was not getting enough

oxygen into his lungs. Using care not to move his head, Ms. Klimko deftly slipped a tube down his windpipe, attached a balloon-like bag connected to an oxygen tank and began to force oxygen into his lungs.

Meanwhile, Wertz inserted a large IV needle into a vein in the man's arm and hung a unit of blood.

The jagged green line cutting across the small screen of the cardiac monitor suddenly went flat.

"He's in arrest," Wertz yelled. Immediately, Ms. Klimko began

compressing the man's chest, forcing his heart to circulate blood while

wi th her other hand continued bagging oxyge~ into his lungs.

Wertz cracked a bright yellow canvas pack holding pre-measured syringes of cardiac drugs and injected 1.0 mg. of epinephrine into the IV tubing. Ms. Klimko momentarily stopped compressions but the EKG line remained flat. Wertz injected sodium bicarbonate and atropine, more drugs to get the heart going. Still no change. More bicarb. More epinephrine. The line stayed flat.

The blood was running wide open but Wertz put a pressure cuff around the bag of blood and pumped it up to force the life-saving fluid through the tube faster. Ms. Klimko kept compressing the chest and bagging.

"We've got to unload hot," Ms. Klimko told Johnston. "He's in full arrest." Johnston passed the information on to the trauma team waiting at West Virginia University's medical center in Morgantown.

The drugs were having no effect on the man's heart and Wertz grabbed a sterile, 3-inch-long needle and inserted it though the wall of the chest. He feared the impact of the collision had collapsed a lung, and blood or air filling the chest cavity might be preventing the heart from beating. But nothing flowed from the open needle.

"We're a minute out," Johnston warned. "Get ready to land."

Ms. Klimko struggled into her shoulder harness while maintaining the rhythm of the compressions.

Fourteen minutes after lifting off from Pine Grove, Johnston landed Life Flight I squarely in the middle of the red cross at WVU's helipad under the eyes of the waiting t rauma team. Thirty seconds later the patient was in the trauma room and doctors were repeating many of the procedures that the flight nurses had tried at 2,000 feet.

Wertz and Ms. Klimko sat on the edge of the empty cabin of the helicopter. Their blue jump suits were black with sweat. The floor and seats of the rear cabin were littered with empty syringes, tubing, rubber gloves, bloody bandages and other signs of the struggle to save a life.

A few moments later, as Ms. Klimko loaded the remnants into a trash bag, Wertz walked out of the emergency room with several cans of soda. "They couldn't save him. They just pronounced him," he told his partner.

"Let's go home," Johnston said, and cranked over the engines.

On the 30-minute flight back to Allegheny General Hospital, the two nurses replayed what they did and agonized over what else they could have done to save the man.

"His injuries were probably too serious for him to survive, regardless of what was done, but the helicopter team gave him every chance there was," Dr. Thomas Vargish, chief of t rauma service at WVU, said later.

"This man is the type of patient who can most likely benefit from rapid air evacuation. Life Flight had a well-trained team on the aircraft who instantly assessed the problem and rapidly started doing what had to be done. They did all that could have been done. Sometimes that's not enough."

Andrew Schneider is Medical Editor for The Pittsburgh Press, and a national correspondant with the Scripts-Howard news service. He is a two-time Pulitzer Award winner for investigative reporting. He has worked very closely with the aeromedical industry, completing 2,000 interviews in 1987. He has been involved in EMS for 20 years, eginning in Vietnam with medevac coverage.

HOSPITAL AVIATION, JANUARY 1988 15