Children are very resilient patients who often do not show signs of a severe illness or injury until they are close to death and then suddenly deteriorate. When this occurs, they require access to neonatal and pediatric intensive care units, which are becoming increasingly limited. Therefore, the care of these neonates, premature infants, and young children is another primary use of Air Ambulance and Medical Flights, with the speed and higher level of care provided en route by an air medical team.
When a pregnant woman experiences complications, they can be life-threatening for both mother and child, and often require the specialized care found in larger hospitals. Timely Air Ambulance transfer to such facilities while the patient(s) receives care from obstetrical/ neonatal specialists has been shown to be safe, cost-effective and beneficial. Transfer via critical care ground ambulance is also successfully employed in these kinds of cases. However, when time is critical and a specialty team from the receiving hospital is sent to bring the patient(s) to the specialty center, air ambulance transport minimizes the out of hospital time for both the patient and the specialty care givers in a way that cannot be accomplished via ground.
Accreditation begins with an application form. The form indicates the service’s intentions to complete the process. The service then receives a Program Information Form (PIF). The PIF consists of a demographic section, a list of bases and a self-evaluation of the service, based on the CAMTS Standards. Response to the PIF self-study also requires attachments that include policies, education materials, quality management and safety processes. The PIF and attachments are submitted electronically within a year of applying for accreditation.
Once the PIF is complete and returned to the CAMTS office, it is reviewed by the CAMTS staff for completeness and sent to two Board members who will review contents for completeness and for additional questions that they document for the site surveyors. Site surveyors are then appointed, based on their experience and background related to the type of service (air/ground; fixed/rotor; critical care, ALS/BLS ground, etc.) they will visit.
The site visit is then scheduled at a time agreeable to both the service and site surveyors and at least 1 month prior to a Board of Directors meeting in order to be placed on the agenda for an accreditation decision. Once onsite the surveyors will conduct a series of interviews of personnel, look at training records, quality improvement programs, safety policies, etc. Their comments and observations are documented for the two Board members who present the program anonymously to the full Board. The programs are always presented by a six digit number – proper names and specific locations are not known by the full Board. If a Board member has a conflict of interest – he or she is excused while the program is presented and the Board deliberates.
Pilots are limited to 12 hour shifts and medical crews typically work either 12 or 24 hour shifts.
There are many but some of the most common are: Nurse/Nurse, Nurse/Paramedic, Nurse/Respiratory Therapist, Nurse/Physician, Paramedic/Paramedic.
A heart attack occurs when an artery in the heart is blocked by a clot, and the heart muscle supplied by that artery is therefore deprived of oxygen. This causes chest pain, and the muscle is in jeopardy of dying. Untreated, these blockages can permanently damage the heart causing death or an otherwise reduced quality of life.
As with critical injuries, there is a window of time (generally thought to be two hours from symptom onset) in which the heart may be effectively treated before it, and the patient, die or are disabled. At any time in this window, the compromised heart may stop or otherwise require emergency treatment to keep the patient alive. Out of hospital, HEMS ALS has proven effective in dealing with these emergencies. Ultimately, these patients need either special medications or surgical procedures at specialist cardiac intervention hospitals to break up the blood clot, allowing blood and the oxygen it brings to return to the affected heart muscle. Done within those two hours, the heart may be undamaged or damage may be limited, allowing the patient not only to live, but to recover a normal life.
Similar to trauma centers, cardiac intervention centers have been developed to provide the more effective of these increasinglycommon surgical treatments. The scarcity of cardiac intervention centers, particularly outside of urban areas, suggest a role, supported by studies to date, for HEMS in quickly transporting patients, even patients whose hearts have stopped and been restarted, from remote hospitals to these centers.
Like heart attacks, some strokes are caused by interruption of blood predominately from a blood clot, only this time in the brain. As in heart attacks, there is a window of time (optimally within 90 minutes but generally no more than three hours) in which clotbusting treatment can result in patients suffering little to no long term damage and disability from these events. Therefore, patients transported to specialty centers for the clot-busting treatment of strokes can benefit from a well-coordinated ground and air system to accomplish early transfer.
From 1972 through September, 2002, when HEMS safety research by Dr. Ira Blumen of the University of Chicago Aeromedical Network (UCAN) was completed, HEMS had flown approximately three million hours, transporting some two and three-quarter million patients. In that time, there were 166 crashes involving HEMS, with 183 fatalities. The UCAN study found that while the number of crashes each year has fluctuated, the number per 100,000 patients flown had dropped from 17.36 in 1980 to 5.5 in 2001.
The risk to patients, estimated over the years of the study, is reported as a fatality rate of 0.76/100,000 patients. Subsequent admission to a hospital carries with it a greater risk of death from complications or errors: various recent estimates range from 1.2/100,000 patents to 292/100,000 patients.
Nonetheless, any form of medical transport incurs inherent risk and in the past few years there have been increased numbers of accidents associated with the increased number of helicopters and transports. In an editorial comment in the UCAN study, a past president of the National EMS Pilot Association emphasizes that the causes of crashes haven’t changed over the years. The top three causes are “risk taking, pre-flight planning, and in-flight decisionmaking,” reflecting the unique pressure placed on crews by the condition of the patient and by the feelings of obligation to fly.
The air ambulance service community has taken significant steps, particularly in the area of aircrew resource management (a proven airline industry safety tool) to improve its safety for patients. Some HEMS prograir ambulance service are replacing aircraft, hiring pilots to fly under Instrument Flight Rules (IFR), and employing new technologies such as night vision goggles (NVG’s) and terrain avoidance warning systems (TAWS), especially important when weather conditions abruptly change mid-mission.80 Transport medicine is among the most complex arenas of medicine, and is characterized by the need to provide immediate access to time-sensitive care for critically ill and injured patients at the same time that operations are conducted in hostile environmental conditions with limited planning time. As Justice Oliver Wendell Holmes once noted: “to be safe does not mean to be risk free.” Recognizing that risk cannot be completely eliminated, it is essential both for the public served, and the pilots, nurses, paramedics, physicians, and other health care providers who deliver care, that the practice environment be as safe as possible.
To that end, the Association of Air Medical Services has already initiated Vision Zero (http://aamsvisionzero.org/) and has joined the International Helicopter Safety Team (IHST, www.ihst.org), led by the American Helicopter Society (AHS), the Helicopter Association International (HAI), the Federal Aviation Administration (FAA), and Transport Canada to reduce helicopter accidents by 80% in the next ten years.
These initiatives seek more effective methods and approaches to avoiding errors in complex systems premised on the model that providers must work collaboratively, on a voluntary basis, with regulators to identify and accelerate the implementation of best practice standards. These efforts focus on developing and implementing strategies using cost benefit analysis and evidence based best practices related to safety in order to prioritize investment and financial plans to result in a goal of zero serious injuries or fatalities.
The agency said it reviewed about 4,000 accidents involving helicopters in the United States, of which 75 commercial helicopter accidents (88 deaths, 29 serious injuries, 42 minor injuries) and 127 helicopter air ambulance accidents (126 deaths, 50 serious injuries, 42 minor injuries) between 1994 and 2008 involved causal factors that are addressed in the proposal.
The Federal Aviation Administration published its 36-page proposed rule this past Tuesday intended to make helicopter air ambulance flights safer nationwide. The proposal will revise Part 91 visual flight rules weather minimums, require all commercial helicopters to be equipped with radio altimeters, require air ambulance flights with medical personnel aboard to be conducted under part 135 (including flight crew time limits and rest requirements), require Helicopter Terrain Awareness and Warning Systems (HTAWS), and require certificate holders with 10 or more helicopter air ambulances to establish operations control centers. Most of these changes fulfill NTSB recommendations made in recent years.
It says they would require training and testing on weather, navigation, flight-monitoring procedures, air traffic control procedures, aircraft systems, aircraft limitations and performance; and, more frequently, on topics specific to each certificate holder, such as aviation regulations and operations specifications, crew resource management, and the local flying area.
Along with requiring a load manifest for all part 135 operations, the proposal defines the role and training of operations control specialists for helicopter air ambulance operations. They will perform safety-sensitive functions “such as providing pre-flight weather assessment, assisting with fuel planning, alternate airport weather minima, and communicating with pilots regarding operational concerns during flight. These duties are similar to those of an aircraft dispatcher, and therefore,” the rule states, “operations control specialists would be subject to the restrictions on drug and alcohol use, and to a certificate holder’s drug and alcohol testing program as described in 14 CFR part 120.”
FAA estimated the proposal will cost the industry $225 million and yield benefits ranging from $83 million to $1.98 billion during a 10-year period.