AeromedicAl trAnsportAtion Aeromedical transportation A clinical Guide 2nd edition t mArtin Royal Hampshire County Hospital, Winchester, UK CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2006 by T Martin CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper Version Date: 20160226 International Standard Book Number-13: 978-0-7546-4148-3 (Paperback) This book contains information obtained from authentic and highly regarded sources Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any 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trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com contents List of Figures List of Tables Preface to the Second Edition Preface to the First Edition Acknowledgements List of Abbreviations Glossary PART I vii ix xi xiii xv xvii xxi INTRODUCTION History of Aeromedical transportation overview PART II 13 PHYSICS AND PHYSIOLOGY the Atmosphere T Martin and M Glanfield 29 the physiological effects of Altitude T Martin and M Glanfield 39 the Biodynamics of Flight T Martin and M Glanfield 55 transmeridian and long Haul Flights 63 PART III OPERATIONAL CONSIDERATIONS operational Aspects of Aeromedical transport 77 the medical Flight crew 97 Aeromedical equipment 109 vi Aeromedical Transportation: A Clinical Guide PART IV CLINICAL CONSIDERATIONS 10 indications for Aeromedical transport 139 11 clinical considerations in transport of the ill and injured 149 12 transport of patients with spinal injuries 173 13 transport of Burns patients 181 14 transport of the obstetric patient 187 15 transport of neonatal and pediatric patients 193 16 critical care transfers and retrievals 209 17 nursing care in the Air T Martin and I MacLennan 217 PART V ORGANIZATION AND ADMINISTRATION 18 the Administration of Aeromedical transport organizations 235 19 medicolegal Aspects of Aeromedical transport 243 20 planning the successful international repatriation 259 21 Primary Transfers: The Casualty Evacuation Conflict 279 Index 285 list of Figures Figure 1.1 Figure 1.2 Figure 1.3 Figure 1.4 Figure 1.5 Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 3.6 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 5.1 Figure 5.2 Figure 6.1 Figure 6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 7.5 A douglas c-47 as used for casualty evacuation in World War ii Sikorsky YR-4 en route to the first helicopter casevac in Burma, 1945 Bell UH-1 Huey, first used in the casevac role in Vietnam Britain’s first helicopter air ambulance, First Air in cornwall (courtesy cornwall & isles of scilly Ambulance service) dedicated air ambulance (shandscair, Florida) search and rescue helicopter of the royal Air Force Boeing md explorer of the london Helicopter emergency medical service Military stretcher fit replacing a block of conventional seats the atmosphere as a column the three layers of the atmosphere the pressure-volume relationship with altitude (dry gases) Boyle’s and dalton’s laws the position of the sun relative to the earth’s surface patterns of air movement caused by vertical air currents the oxygen partial pressure gradient from dry atmosphere to minimum pressure level the oxygen dissociation curve at 37oc and pH 7.4 Arterial po2 up to 20 000 ft (6100 m), breathing air the concentration of oxygen required in the inspired gas to maintain alveolar po2 of 13.3 kPa (100 mmHg) relationship between gas volume and pressure at altitude linear acceleration radial acceleration example of time-zone map Virgin Atlantic Airways aromatherapy kit sleep epochs either side of westbound and eastbound long haul flights Gates learjet Raytheon Hawker 125/700 Beechcraft super King Air B200 Fairchild metroliner eurocopter (Aerospatiale) dauphin 10 11 15 17 19 30 31 32 33 34 35 41 42 47 48 49 56 57 64 68 69 83 83 84 84 85 viii Figure 7.6 Figure 7.7 Figure 7.8 Figure 8.1 Figure 8.2 Figure 9.1 Figure 9.2 Figure 11.1 Figure 11.2 Figure 11.3 Figure 11.4 Figure 12.1 Figure 12.2 Figure 15.1 Figure 15.2 Figure 15.3 Figure 19.1 Figure 19.2 Figure 20.1 Figure 20.2 Figure 20.3 Aeromedical Transportation: A Clinical Guide Eurocopter (Bolkow) BK117 eurocopter ec135 Agusta Westland 109 Flight nurse and patient during a repatriation mission Flight physician and paramedic team Using a cargo lift for stretcher access to a commercial airliner An integrated loading and patient carriage system dedicated air ambulance note the space restrictions and difficulty with stowage and access to equipment Immobilization of the head and neck in suspected cervical spine injury Altitude equivalents for various levels of hemoglobin Risk of rebleeding after an aneurysmal SAH povey turning frame being loaded onto a military Vc10 strategic casevac aircraft Vacuum mattress conforms to the patient’s body contours intravenous access is often necessary before leaving the referring hospital or scene of injury BmJ paediatric resuscitation chart nicU transport incubator typical air ambulance transfer documentation typical Hems documentation Stretchers stacked on special mountings Embarkation may best be achieved by means of an elevator loading a stretcher onto an air ambulance note the difficulty with access and lifting 85 86 86 99 99 111 115 150 152 160 166 176 176 198 199 206 249 251 271 272 273 list of tables table 2.1 table 4.1 table 6.1 Table 6.2 Table 6.3 Table 7.1 Table 7.2 table 7.3 table 7.4 table 7.5 table 7.6 table 7.7 table 8.1 table 9.1 table 9.2 table 9.3 table 9.4 table 10.1 table 10.2 table 10.3a table 10.3b table 10.3c table 10.3d Features of the swedish national Air medevac program 21 the time of useful consciousness up to 36 000 ft (10 930 m) 53 American standard times 64 Flight time limitations for air ambulance flight crew 70 Summary of proposals for flight time limitations for aeromedical personnel 71 Performance data for commonly used fixed wing air ambulances 80 Typical fixed wing air ambulance cabin dimensions 80 comparison of typical helicopter air ambulances 82 safety matrix: factors in crash prevention and survival 89 essential issues of agreement between the aviation and medical components of an aeromedical transport system 92 safety related policies/standard operating procedures 92 radio frequency band characteristics 95 A model curriculum based on the Air Medical Crew National Standard Curriculum (UsA) 104 Hems typical onboard medical equipment and specialist kit 112 Hems typical portable medical equipment 112 Recommendations of the RSM working party on minimum standards in medical helicopter systems: minimum acceptable equipment 114 typical air ambulance equipment 116-117 Guidelines for the use of aeromedical transport in trauma patients 140 interhospital triage criteria 140 Guidelines for the use of aeromedical transport in non-trauma medical and surgical patients 141 Guidelines for the use of aeromedical transport in non-trauma pediatric patients 142 Guidelines for the use of aeromedical transport in non-trauma neonatal patients 143 Guidelines for the use of aeromedical transport in non-trauma patients in whom aeromedical transport is not indicated 143 276 Aeromedical Transportation: A Clinical Guide consumables medical waste and used sharps should be correctly disposed of at the receiving hospital On return to the base office, a copy of the transfer document should be placed on file and all equipment returned and replenishment arranged, ready for the next assignment Table 20.7 Definitions Suggested medical escort flight time limitations • duty time • period between arrival at base office for briefing and collection of equipment, and arrival at destination hotel for first rest (that is, after seeing patient, if applicable) • minimum rest time • minimum time between arrival and departure from the patient’s location this period should not include time spent traveling to or attending the patient, nor the transfer of the patient to the airport optimum minimum rest time • 1.5 x the previous duty time plus one hour for every time zone crossed Flexibility • in the interests of economy, if the next available flight departs more than 12 hours after the end of the minimum rest time, or involves an extra overnight stop, the minimum rest time can be reduced at the discretion of the medical director and with the escort’s agreement References Air medical physician Association (2003) ‘medical condition list and appropriate use of air medical transport’, Air Med J 22(3):14-9 Dewhurst, A.T., Farrar, D., Walker, C., Mason, P., Beven, P and J C Goldstone (2001) ‘Medical repatriation via fixed-wing air ambulance: a review of patient characteristics and adverse events’, Anaesthesia 56(9):882-7 Fairhurst, r.J (1992) ‘Health insurance for international travel’, in: dawood r (ed.) Travellers’ Health (3rd ed.), oxford University press: oxford macnab, A.J., noble, r., smart, p and G Green (1998) ‘narcotics and controlled drugs: a secure system for access by transport teams’, Air Med J 17(2):73-5 Planning the Successful International Repatriation 277 martin, t.e (1993) ‘transportation of patients by Air’, in Harding and mills, Aviation Medicine (3rd ed) BmJ: london neri, m and r de Jongh (2004) ‘medical and trauma evacuations’, Clinics in Occupational & Environmental Medicine 4(1):85-110 Parsons, C.J and W.P Bobechko (1982) ‘Aeromedical transport: its hidden problems’, Can Med Assoc J 126(3):237-43 preston, F.s (2003) ‘commercial aviation and health – general aspects’, in ernsting J., nicholson, A.n., and d.J rainford (eds) Aviation Medicine (3rd ed.), Arnold: london Wilde, H., Roselieb, M., Hanvesakul, R., Phaosavasdi, S and C Pruksapong, (2003) ‘expatriate clinics and medical evacuation companies are a growth industry worldwide’, J Travel Med 10(6):315-7 chapter 21 primary transfers: the casualty Evacuation Conflict of the many controversial issues surrounding the prehospital management of the victims of trauma, the decision to evacuate or stabilize on site is probably the one most often criticized In a mass casualty situation this decision takes on a much greater significance In brief, a multi-casualty incident can be defined as an incident where more than one patient requires transportation and treatment, but where the local facilities are able to cope on the other hand, a mass casualty situation occurs when the local emergency services are initially overwhelmed and are only later able to respond with reinforcements A disaster, however, is a poorly defined term which implies that the emergency services are totally overwhelmed or are themselves impaired by the incident It can be qualified by information on the circumstances surrounding the incident, such as the cause, location, environmental conditions and so on Since the very first ambulance units were formed (originally by the military), speedy evacuation from the scene of wounding has been a major objective in the management of the injured during the Vietnam War, this ‘scoop and run’ concept may have been partly responsible for the saving of many lives, thanks mainly to the rapid transportation system afforded by helicopters, and the proximity of excellently equipped, multi-speciality medical facilities Had these patients to face the ‘treatment vacuum’ of a long and arduous journey, many of those who survived initial wounding might have perished during what has been called the ‘golden hour’ since the 1960s there has been growing concern over the management of civilian victims of trauma, not least in the standard of prehospital care which they receive Following the lead taken by the USA, Advanced Trauma Life Support (ATLS) training was introduced into the UK in 1988 and was rolled out worldwide in the subsequent decade Although it is a hospital-based training package it provides an excellent gold standard by which to measure all levels of trauma management the newer Prehospital Trauma Life Support (PHTLS) course was designed specifically for those who work at the coalface of emergency medicine, and this has been followed by the prehospital paediatric life support (pHpls) course in the UK most ambulance authorities now aim to provide all frontline emergency vehicles with equipment and personnel able to provide basic trauma life support paramedic training has been introduced in many western countries and is constantly under review In addition, the training of doctors in immediate medical care skills is increasing in popularity, thanks largely to the British Association of Immediate Care 280 Aeromedical Transportation: A Clinical Guide schemes (BAsics) and the establishment of the Faculty of immediate care at the royal college of surgeons in edinburgh, as well as similar programs in europe, north America and Australasia Globally, there is an increasing awareness of the need to correctly treat the seriously injured before evacuation to hospital and we are gradually acquiring the skills, expertise, equipment and personnel to so There is little doubt that the best treatment occurs in countries with abundant well equipped hospitals, good road communications, reasonable coverage by emergency vehicles, and a network of ems helicopters which can cater for large urban expanses (where there is a high density of trauma) and for large rural gaps (where there is a low density of ambulance cover) How, then we decide whether to ‘scoop and run’ or to ‘stay and play’ with the trauma casualty? clearly, there is no single answer for all situations, and a few examples will highlight the difficulties: in some geographic locations and under some circumstances, the environment and availability of assets dictate the answer For instance, when search and rescue helicopters are utilized to retrieve casualties from mountains, moors or the sea in most cases the survivor is rescued from a hostile environment and, although limited medical care may be possible onboard the helicopter, little or nothing can be done at the scene At the roadside, in the single casualty situation, if a road ambulance is on scene within a few minutes and the nearest emergency room is nearby, although much could be done for the patient, with appropriate facilities so close, speedy evacuation is warranted and only the essentials should be attempted If entrapment delays evacuation, one must ask how serious are the injuries, and will the patient survive the extrication process without the provision of advanced resuscitation skills? Resuscitation and stabilization on scene may be essential in these cases, but it should not unnecessarily delay extraction the caveat is, of course, that the extrication process, itself, must not prevent urgent medical actions in a multicasualty situation, other ambulances will be required and the surrounding roads may be congested as a result of the accident the nearest hospital may not have the required specialist facilities, such as burns, neurosurgery and cardiothoracic surgery The questions then to ask are: who needs to be evacuated immediately, and to where? Who can be retained, and why? Care must be taken to avoid a bottleneck at the nearest emergency room, thereby delaying definitive care for those in most need Who should provide immediate medical care? Ambulance technicians are familiar with roadside scenarios and, although trained and equipped paramedics quite clearly influence the survival and outcome of many casualties, they are still limited by the extent of their skills At the other end of the scale, most hospital doctors, without proper training in prehospital management, work best in a familiar environment, with familiar equipment, and with the teamwork and support services that are normally provided in a hospital Immediate care trained doctors, whether community or hospital-based, are likely to be able to cope with most incidents, even more so if they have anesthetic and Primary Transfers – The Casualty Evacuation Conflict 281 surgical skills Many family practitioners are now vastly experienced in the roadside management of serious injuries They work closely alongside their paramedic colleagues, supporting, supplementing and supervising their medical capabilities in complicated and multiple trauma situations some hospitals are now able to provide mobile medical teams (previously known as ‘accident flying squads’) for complicated incidents in general, these teams will have been trained and equipped for the prehospital environment and will have suitable transport and communications to act independently, yet under the control of the medical incident officer at the scene When evacuation of many casualties is needed, decisions must also be made about the most suitable mode or methods of transport perhaps by using road ambulances, buses or trucks, by rail or underground, by sea or by air However, the old adage that ‘evacuation is important but resuscitation is a priority’ is still true Every medical student knows that shocked patients travel poorly In fact, any patient who has an unstable airway, breathing or circulation undertakes a perilous journey when he is scooped away from the scene of injury Although speed is important in transferring critically injured patients from the incident to hospital, it is secondary to safety and ongoing management of life threatening conditions When faced with a delay in evacuation or a journey lasting more than a few minutes, each patient should preferably be stabilized and ‘packaged’ appropriately for a safe transfer Monitoring and continual reappraisal during transportation is essential it is now common to see military and civilian helicopters at the sites of major accidents and disasters At incidents on or near airports, it should be remembered that fixed wing aircraft can be used to transfer patients over long distances, although this mode of transfer is usually utilized for secondary or tertiary referrals, and for repatriation from overseas after life-saving treatment has been completed often a mixture of ground and air ambulances is required, and it should be remembered that helicopters can be used to bring skills and equipment to the accident scene in addition to taking patients away from it For small contained incidents, though, the helicopter can usefully be utilized as a mobile intensive care unit, thereby extending the therapeutic arm of the hospital into the community So, having started with a grand aim – to resolve the casualty evacuation conflict – the situation is perhaps now more confused by the illustration of the many pitfalls that may be encountered ideally, the aim is to provide the best possible care for those patients with greatest need However, to ensure the maximum benefit to the largest number, triage must be used, and it must be performed by the most experienced resuscitation trained person on site (not always a doctor) triage will not only decide the priorities of treatment, but also the priority for evacuation, since the patient with an unresolved airway problem (A) is likely to die before the patient with a breathing problem (B) who, in turn, is likely to die before the patient with a circulatory problem (c), and so on triage is essentially a dynamic process casualties must be continually reassessed and priorities must be changed in the light of clinical deterioration or improvement Aeromedical Transportation: A Clinical Guide 282 And so to the decision-making process The essential point is that there is no single, simple, universal answer decisions must be made by the person in control at the scene if that person is not aware of the extent of the incident (and that may not be easy in the early minutes or hours of a significant catastrophe), or if he is not in communication with those at the workface, any decisions made will be based on an inappropriate model of events there is no authoritative advice, but the aim must always be to treat those who are salvageable, and in most urgent need, first Delay in definitive care will cost lives If nearby hospitals are blocked by an early wave of minor injuries and these hospitals are unaware of the extent of the backlog still to come, those in most need will die waiting for attention Table 21.1 lists the information which is therefore essential before making decisions on which casualties should be held, which should be stabilized, which should be evacuated first, and of course, by which means Although there are no easy answers, it is essential, at least, to be aware of the potential problems If all else fails, ask yourself ‘where is the potential medical bottleneck going to be and what can I to prevent it?’ Table 21.1 • • • • • • • • • • • • • • • • • Considerations in casualty evacuation number of casualties numbers in each triage group Will there be delays in extrication? Are further casualties expected? Quality and quantity of medical assets on site Quality and quantity of medical personnel on site Access to incident site and transport available distance and time to nearest medical facilities Appropriateness of local hospitals (for example, neurosurgery, burns) capabilities of local hospitals (for example, beds, operating rooms) capabilities of nearest specialist hospitals Ability to hold and treat casualties on site possibility of on-site medical reinforcement/supplies condition of roads and communications Availability of helicopter landing sites Flight times to medical facilities local weather and environmental conditions References Berns, K.S., Caniglia, J.J., Hankins, D.G and S.P Zietlow (2003) ‘Use of the autolaunch method of dispatching a helicopter’, Air Med J 22(3):35-41 Cameron, P.A., Flett, K., Kaan, E., Atkin, C and L Dziukas (1993) ‘Helicopter retrieval of primary trauma patients by a paramedic helicopter service’, Aust N Z J Surg 63(10):790-7 Primary Transfers – The Casualty Evacuation Conflict 283 Falcone, r.e., Herron, H., Werman, H and m Bonta (1998) ‘Air medical transport of the injured patient: scene versus referring hospital’, Air Med J 17(4):161-5 Garner, A., rashford, s., lee, A and r Bartolacci (1999) ‘Addition of physicians to paramedic helicopter services decreases blunt trauma mortality’, Aust N Z J Surg 69(10):697-701 Hotvedt, r., Kristiansen, i.s., Forde, o.H., thoner, J et al (1996) ‘Which groups of patients benefit from helicopter evacuation?’ Lancet 347(9012):1362-6 law, d.K., law, J.K., Brennan, r and H.c cleveland (1982) ‘trauma operating room in conjunction with an air ambulance system: indications, interventions, and outcomes’, J Trauma 22(9):759-65 Martin, T.E (1993) ‘Resolving the casualty evacuation conflict’, Injury, 24(8)514-6 mccann, J.p., Burnett, J.r and F.m Holmstrom (1970) ‘potentials of the Aeromedical evacuation system in the overall treatment process for the seriously ill patient’, Aerosp Med 41(3):323-8 royal college of surgeons of england (1988) ‘the management of patients with major injuries’, rcs: london Skogvoll, E., Rygnestad, T (1997) ‘Helicopter emergency medical service’, Lancet 348(9026):543-4 thomson, d p and s.H thomas (2003) ‘Guidelines for air medical dispatch’, Prehospital Emergency Care 7(2):265-71 tomazin, i and t Kovacs (2003) ‘medical considerations in the use of helicopters in mountain rescue’, High Alt Med Biol 4(4):479-83 Travis, D.T and M Lozano (2004) ‘No-fly zones: Hillsborough County defines urban grids where ground transport of trauma patients makes the most sense’, J Emerg Med Serv 29(5):116-8 Trunkey, D D (1983) ‘Trauma’, Scientific American, Vol 249, pp 20-27 Trunkey, D D (1985),‘Towards optimal trauma care’, Arch Emerg Med, Vol 2, pp 181-195 index AAms, 94, 144, 236 ABcd assessment, 149 abdominal distension, 51 acceleration linear, 55, 56 long duration, 55 physiological effects of, 55 radial, 57 accident survivability, 89, 90 acquired immune deficiency syndrome, 169 adiabatic lapse rate, 31, 34 adrenal crisis, 168 advance statement, 246 aeromedical aircraft, 14, 20, 77–80, 83, 84, 93 specifications, 77–80 aeromedical escort’s duties preflight, 268, 269 outbound, 269, 270 patient collection, 269, 270 at the airport, 269, 274 en route, 269, 274 on arrival, 269, 275 aeromedical transport, 8, 9, 10, 11, 14, administration, 235–241 civilian fixed wing, 11, 18 contraindications, 146, 147 efficacy, 8, 11, 100, 157, 194, 238, 240, 241 history, 3–11, 20 indications, 139–143 mission profiles, 77 operational aspects, 77–95, 101, 102, 104, 129, 149, 236 organizations, 22, 23, 103 outcome indicators, 144 policies and protocols, 91, 92, 102, 104, 235, 236, 250, 252, 267 types of services, 13, 14 Aerospace medical Association, 23 Aerospatiale dauphin, 85 Aids, 169 air ambulance companies, 11, 18 air ambulances, 80, 82, 111, 113, 130, 145, 150, 188, 212, 266 indications for, 266 Air medical physician’s Association , 22 air sickness, 60 air taxi, indications for, 266 air, 29, 31 aircrew, 70, 90 airlines, 124, 125, 145, 146, 150, 169, 213, 218–223, 229, 254–256 co-operation with medical assistance, 260–267, 271, 275 airway, 151, 152, 173, 181 intubation, 151, 162, 163, 164, 182, 183, 194 obstruction, 42, 105, 151, 164, 181 pediatric, 194, 195 surgical, 151, 181 altitude, 32 physiological effects, 39–53 restrictions in disease, 152–155 alveolar air, 39 AmpA, 22 anemia, 42, 157–159, 119 aromatherapy, 67, 68 arrhythmias, 45, 105, 142, 147, 155, 157, 158, 165 AsmA, 23 Association of Air medical services, 144, 236 atmosphere, 29–37 as a column, 30 atmospheric pressure, 30, 32, 33, BAmpA, 71, barosinusitis, 50, 181 barotitis media, 49, 50 Battle of Britain, 14 Bell UH-1 iroquois (Huey), bends, 39 biodynamics, 55–61 286 Aeromedical Transportation: A Clinical Guide birth in flight, 243, 255, 256 Boyle’s law, 32, 33, 37, 48, 128, 153, 203, 229 British Aeromedical practitioner’s Association, 71 British Association of immediate care, 279 British summer time, 64 buffeting, 56 burn injuries, 155, 181–185 airway, 181 escharotomy, 182 pulmonary function, 182 fluid replacement, 182, 183 electrolyte abnormalities, 183, 184 infection, 184 metabolic rate, 184 cAAms, 22, 236, 238 cabin pressurization, 46, 52, 53 caisson disease, 39 capnography, 46, 59, 120, 121, 128, 195, 212 carboxylic acid cycle, 39 cardiac monitoring, 104, 122, 123, 155, 156 cardiopulmonary resuscitation, 78, 120, 126, 156 cardiotocography, 188 cardiovascular conditions, 105, 155–159 cardioversion, 157 casts, orthopedic, 166 casualty evacuation, considerations in, 279–282 cerebrovascular accident, 43, 104, 147, 155, 164, 191, 220 chokes, 39 circadian rhythms, 65, 67, 71 civilian helicopters, 8–10, 16, 81 clear air turbulence, 57 clinical considerations, 149–206 airway, 151 burn injuries, 181–185 cardiovascular, 155–160 care of the cervical spine, 173–178 endocrine, 168 gastrointestinal, 168 general, 170 infectious diseases, 169 neurological and neurosurgical, 160–166 obstetrics, 187–191 ophthalmic, 169 orthopedic, 166, 167 pediatric and neonatal, 193–206 psychiatric and psychological, 170 respiratory, 152–154 spinal injuries, 173–178 cockpit resource management, 90 colostomy, 168 commission on Accreditation of Aeromedical services, 22, 236, 238 communications, 59, 78, 88, 90, 93–95, 112, 212 concorde, 36 confidentiality, 231, 232, 243, 250, 262, 265, 267 congestive heart failure, 142, 147, 157, 159 consent, 200, 228, 231, 232, 244, 245, 246, 250, 265 continuous quality improvement, 102, 236, 238, 239 contraindications to flight, 146–147, 150, 271 controlled drugs, 253 convention on international civil Aviation, 70 convulsions, 163, 167 coordinated universal time, 63 corticosteroids, 168 cpr, 78, 120, 126, 156 craniotomy, 164 crash restraint, 56, 272 creeps, 39 crm, 90 daedalus, dalton’s law, 33, 203 DC shock, 123–125, 157 de Havilland dH 50, dH 9, death in flight, 146, 156, 243, 255, 256 decompression sickness, 39, 52, 142 defibrillation, 123–125, 157 defibrillators, 112–114, 125, 213, 218 diabetes, 147 disaster, 5, 15, 20, 104, 130, 158, 279 training in immediate care, 234, 235 doctors as aeromedical escorts, 97, 98, 268 Index training in immediate care, 279, 280 documentation, 102, 177, 215, 243, 247–251 Douglas DC3 Dakota, dysrhythmias, 45, 105, 142, 147, 155, 157, 158, 165 Earth’s magnetic field, 35 economy class syndrome, 187 elderly patients and passengers, 139, 149, 164, 260 electrical burns, 155 electrical power supply, equipment, 128, 129 emergency medical systems, 9, 10, 238 emphysema, 147, 154 endocrine conditions, 168 entrapment, 16, 280 epilepsy, 147, 164, 165 equipment, 109–133 auscultation, 59, 112, 117, 188 effects of gas expansion, 120 flight medical bag, 115, 214 flight nursing bag, 111 in prehospital operations, 111, 112, 114 monitoring, 119–122, 212 purchase, 126 pediatric, 197 requirements, 126–129 servicing, 129, 130 standardization, 130–133 therapeutic devices, 117–119, 122–126, 212–214 eUrAmi, 23 european Aero-medical institute, 23 exportation of drugs, 253 external fixators, 166 eye injuries, 169 facial injuries, 147, 164 fat embolism, 167 First Air, cornwall, 10 first manned ascent, First World War, fits, 163, 167 fixed wing aircraft, 77–80, 83, 84 flatulence, 168 flight time limitations, 70–71, 276 fluid overload, 56 Flying doctor service, 5, 18 287 flying phobia, 60, 149, 170 Flynn, reverend John, fractures, 166, 167 Franco-prussian War, Franklin, Benjamin, Frenzel maneuver, 50 future, 23, 36, 127, 128, 162, 241 G forces, 55–58 gaseous expansion, 48, 49, 53, 128, 154, 168, 169, 198, 245 gastrointestinal conditions, 51, 147, 168, 198, 204 bleed, 168 gas, 51, 230 infection, 168 Glasgow coma score, 140, 145, 160–165 glaucoma, 169 golden hour, 24, 279 Good samaritan acts, 244–246 gravity, 29 Greenwich mean time, 63, 64, 67 guidelines for medical transport trauma, 140 non-trauma, adults, 141 non-trauma, pediatrics, 142 non-trauma, neonatal, 143 hand injuries, 167 handover, 71, 171, 173, 177, 178, 275 head injuries, 104, 160 helicopter emergency medical services, 9–11, 13, 17, 17, 81, 111–113, 243, 280 ems helicopters, 81, 82, 86 helicopters, 81, 82, 86 hemothorax, 105, 155 Huey, hypoxia, 39, 42 effects on the cardiovascular system, 44 effects on the central nervous system, 43 effects on the respiratory system, 44 physiological stages, 45 treatment, 46 use of supplemental oxygen, 46 icarus, ileostomy, 168 ileus, 49, 51, 60, 168, 177 288 Aeromedical Transportation: A Clinical Guide importation of drugs, 253 incubators, neonatal, 73, 114, 187, 203–205 infectious diseases, 169 international health regulations, 169, 243, 253, 254 universal precautions, 169 Inflight Nurses Association of the Royal college of nursing, 23 initial assessment, 149 integration of services, 16, 238 interhospital triage criteria, 140, 238 international date line, 63 international health regulations, 169, 243, 253, 254 international society of Aeromedical services, 23 intracranial pressure, 56, 104, 160–162, 199 intubation, 151, 152, 162–164, 181, 183, 194, 195 isAs, 23 jaw fracture, 141, 164 jet lag, 65–68 Junkers JU 52, jurisdiction, 243, 252, 255, 256 Kitty Hawk, Korea, 15 Kreb’s cycle, 39 landing zones, 13, 92, 93, 238 laparotomy, 168, 264 latitude and longitude, 63 lethal corners, 165 liability, 237, 243, 245–248, 250, 258 living will, 246 logistic factors, 22, 72 london Hems, 17 long haul flights, 63–68, 72, 157, 275 luftwaffe, malaya, manned ascent, first, maryland Hems, mass casualty situation, 279 mass transportation, 11 medical antishock trousers, 166 medical assistance, 11, 18, 19, 23, 113, 244, 243, 259–261, 267 desk doctor, 260, 261 difficult clients, 267 mediF forms, 264 medical reports, 261 seat upgrades, 264 serious patients, 262 medical director, 89, 92, 145, 169, 236–238, 262, 263, 266, 268, 276 medical flight crew, 97–105 crew configuration, 97–99 crew efficacy, 100 training, 101–105 medicolegal aspects, 243–257 advance statement, 246 assault, 246 birth and death in flight, 255, 256 confidentiality, 231, 232, 243, 262, 265, 267 consent, 200, 245, 246, 250, 265 not resuscitate policies, 252 documentation, 102, 177, 215, 243, 247–250, 261, 263 Good samaritan regulations, 244, 245 guidelines for clinical management, 250, 255 handover, 71, 171, 173, 177, 178, 275 import and export of drugs, 253 international health regulations, 169, 243, 253, 254 jurisdiction, 243, 252, 255, 256 liability, 237, 243, 245–248, 250, 258 living will, 246 negligence, 246, 247 no fault liability laws, 247 standards of care, 243, 250 melatonin, 65, 67 military antishock trousers, 166 Military Assistance to Safety and Traffic program, 9, 15 military helicopters, 15 motion sickness, 58, 60, 149, 162, 168, 177, 198 multi casualty situation, 279 myocardial contusion, 155 myocardial infarct, 155 myocardial ischemia, 155, 158 negligence, 246, 247 neonatal considerations, 105, 143, 200–206 Index cyanotic congenital heart disease, 204 diaphragmatic hernia, 203 gastrochisis, 204 hypothermia, 202 intestinal obstruction, 203 omphalocele, 204 physiology, 201, 202 respiratory distress, 203 neurological and neurosurgical conditions, 160–166 noise, 59, 224 ophthalmic conditions, 166, 167 orthopedic conditions, 166–167 oscillation, 58 otic barotrauma, 46, 49, 198 outcome indicators, 144 oxygen carriage, 40, 43, 35, 46, 153, 155, 191 hemoglobin dissociation curve, 41, 42, 44, 119, 202, partial pressure, 33, 40, 41, 43, 119, 149, 153, 204 requirements, 46, 118, 121, 203, 213 saturation, 40–42, 45, 46, 119, 121, 153, 155, 162, 173, 182, 195 systems, 118 ozone, 36 pacemakers, 59, 104, 123, 142, 158 paediatric, see pediatric paramedics, 11, 15–17, 98, 100, 101, 205, 214, 236, 238, 245, 247, 250, 279, 280, 281 partial pressure, 33, 40, 41, 43, 119, 149, 153, 204 pediatric conditions, 105, 142, 193–206 drug dosage, 197–199 equipment, 197–199 fluid replacement, 197 gaseous expansion, 198 normal physiological parameters, 197 ventilation, 196 performance on duty, 70–71 plaster of paris casts, 166 pneumothorax, 51, 53, 105, 143, 147, 154, 155, 203, 271 pregnancy, 187–191 amniotic fluid emboli, 191 289 maternal anatomy and physiology, 187 precipitous delivery, 190 pre-eclampsia and eclampsia, 190 pregnancy induced hypertension, 190 premature rupture of membranes, 190 preterm labor, 190 vaginal bleeding, 189 prehospital equipment, 112 pressurised antishock garment, 166 primary transfer, 13, 16 psychiatric and psychological conditions, 170 psychosis, 170 pulmonary embolism, 105, 174 pulse oximetry, 46, 104, 119, 127, 155, 158, 212 pyrexia, 155, 167 QAntAs, 4, 124 quality assurance, 102, 236, 238, 239, 241, 247 quaternary transport, 14 radiation cosmic, 35 background, 36 ionising, 35 solar, 34, 36 radio, 94, 95 rAF, 5, 14, 215 rapid decompression, 39, 5–53, 109, 133 research, 240–241 respiratory conditions, 152–155 respiratory physiology, 39–49 royal Air Force, 5, 14, 215 royal Flying doctor service, safety, 87–93 sAmU, 10 sAr, 13, 14, 15 scene flights, 13, 279–282 scoop and run, 279 scoring systems, injury and illness, 105, 145 search and rescue helicopters, 14, 15 search and rescue, 6, 7, 13, 14, 15, 81 second World War, 5, secondary transfers, 13, 16 seizures, 45, 162, 163, 190, 191 sensory conflict theory, 60 290 Aeromedical Transportation: A Clinical Guide service d’Aide médical Urgente, 10 shock, 43, 105, 141, 167, 173, 188, 197 sickle cell anemia, 159 siege of paris, 3–4 sinus barotrauma, 50 solar flares, 36 spanish civil War, spinal injuries, 73, 104, 105, 155, 173–178 complications, 173–175 immobilisation, 110, 152 lifting and moving, 175–176 primary transfer, 175 secondary transfer, 175 spinal care, 152, 246 traction, 177 turning, 110, 175 staggers, 39 standard time, 63 standards of care, 245 stratosphere, 31, 34, 57 stretchers, 73, 90, 113, 145, 110, 175, 219, 225, 227, 231, 263, 269, 271–272 subarachnoid hemorrhage, 165, 262 sun spots, 36 survivability, 89–90 synchronized cardioversion, 157 tertiary transfers, 13 thalassemia, 159 thyrotoxicosis, 155 time of useful consciousness, 53 time zones, 63, 65, 67, 70, 71, 169, 248 traction, 58, 110, 112, 166, 175, 177 transmeridian flight, 63–68 transpolar travel, 36 trauma centers, 17, 140 travel insurance, 14, 19, 20, 259, 268 triage, 94, 104, 140, 238, 281 troposphere, 31, 32, 34, 57 turbulence, 31, 35, 58, 60, 226 utilization review, 144 vaccination, 18 ventilation/perfusion mismatch, 40, 42,153, 154, 174, 195 ventilators, 46, 104, 112–114, 118–119, 128, 212, 213 vibration, 58 Vietnam War, 8, 15, 279 wake turbulence, 35 weather, 14, 22, 31, 34, 35, 72, 87, 89, 211, 282 World Health organization, 169, 253, zeitgebers, 65