Dr. Sunil SookramMAvMed, MD, CCFP, FRCPC

Clinical ProfessorDepartment of Emergency Medicine

University of AlbertaMedical Director: AHS IFS & Dispatch, STARS Grande Prairie

Objectives

To showcase current Civil Aviation Medical Response Resources

To highlight areas of physician involvement in Aeromedical Transport

To explore how Retrieval Medicine has evolved in Canada.

Today’s Educational Journey

3 real clinical vignettes

Case #1 – Airline Role

Case #2 – Member of Transport Team

Case #3 – Quarterback of Patient Care

Case #1

Flying on a Malaysian Airlines flight B737 –Hong Kong to KL

Steward comes over to you about 2 hrs into flight (3.5 hrs)

Have a sick patient in the back and wonder if you can help out and have a look.

Situational Awareness

Flight Manifest contains titles (Dr.)

Most airline flights have someone (Dr., Nurse, Paramedic) that has advanced medical training statistically

Airlines have a medical kit and most have AED - even discount airlines

North American Airlines and many international airlines subscribe to Medical Assist Companies that provide 24/7 online medical support (i.e. MedLink)

The Sequence of Events

Patient assessed, while navigating medical kit patient starting vomiting and then suddenly arrested

Cardiac arrest run on plane utilizing AED and ACLS drugs within medical kit – help from travelling ICU Nurse and my wife

Kit has limited Epi, bicarbonate, crystalloid fluid because of weight and size

Need to liaise with pilot through flight attendants letting them know progress and medical needs.

The Aircraft Commander (Captain) will make logistical and operational decisions on diversion based upon information provided.

Back to case

Decision to divert was withheld as we were over the sea and 1.5 hrs to destination

Rapid descent process employed to get us on the ground and can hurt ear drums and added vestibular issues of other passengers

Very captive audience watched rescuscitation versus onboard entertainment system

Work with aircrew to meet patient’s immediate needs

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Table 1.

Study characteristics and incidence of in-flight medical emergencies.

Authors Journal Dates Study Design

Total # ofCasesreported Incidence Diversion

CardiacArrest/Death

Hung et al Arch Int Med2010

01/2003–01/2008

RetrospectiveCohort, SingleAirline-HongKong

4068/5years

Appx. 11.63 perbillion revenuepassenger killometers

46 (1.1%) 30 (0.7%)

Sand et al Crit Care2009

01/2002–12/2007

Retrospective 2Airlines-Europe

10,189/5years

Appx. 14 (+2.3) perbillion revenuepassenger kilometers

279(2.7%)

52 (0.5%)

Baltsezack,S

J TravelMed. 2008

01/2006–01/2007

RetrospectiveSingle Airline-Asia

191/1Year

Not Analyzed NotAnalyzed

1 (0.5%)

Qureshi etal

E MedJournal 2005

06/2002–12/2002

RetrospectiveSingle Airline-Edinburgh

507/6months

Not Analyzed NotAnalyzed

Not Analyzed

Delaune etal

Aviat SpaceEnviron Med2003

07/1999–06/2000

Retrospectivesingle airline.

2965/1year

22.6 per millionpassengers

181(7.9%)

7 (0.1 permillionpassengers).

Dowdall,Nigel

BMJ 2000 03/1998–03/1999-

RetrospectiveSingle Airline-

3386/1year

Appx. 1 per 11,000passengers

NotAnalyzed

Not Analyzed

Take Away Lessons for EM Physicians

Be prepared

Utilize the resources at hand (people, equipment, online support)

Work with Aircraft Commander to make informed decisions factoring patient need and operational decisions

Case #219 yo female drinking and driving. Car stuck lamp pole and drove front end of car posteriorly. Pttrapped in car for prolonged period. 2.5 hrs trying to extricate

“Remove vehicle from patient”

Due to lengthy period of entrapment, primarily 1 very trapped leg under dashboard, consideration of field amputation is made by on scene commander .

Aeromedical crew sent out to transport. Physician accompaniment

The Role of The Physician on Scene

Limited

Aeromedical crews highly trained and get enhanced training and experience compared to their ground based colleagues

Role of Physician on on Mission:Master Triager (Disaster Scene)Advanced skills (USS, Central Line, Chest Tube, RSI)Unique situations (Obstetrics, field amputation)

Strategic Medevac – InterfacilityTransfer

Long Distance (transAtlantic, transPacific), foreign countries

Facilitates transfer of care (heterogenousmedical capabilities around world)

Bringing definitive care to patient on occasion

Medical Diplomacy – building bridges, “field supervision”, teachable moments for rural providers.

Case #3: Patient Quarterback

ORNGE Transport Physician Consultant

STARS Transport Physician

BC – Emergency Physician On line Support

“The Future of Physician On Line Medical Support for a Transport System”

Air Ambulance Bases

Alberta

10 Air Ambulances Bases

11 KA 200 24/7• High Level• Ft. Vermillion• Peace River (2 AC)• Fort McMurray• Slave Lake• Grande Prairie• Lac La Biche• Edmonton• Calgary• Medicine Hat

3 STARS Bases• Calgary• Edmonton• Grande Prairie

High LevelFt. Vermillion

Peace River Ft. McMurray

Slave Lake

Lac La BicheGrande Prairie

Edmonton

Calgary

Medicine Hat

Case #2

Nov 3rd 2 calls occurring simultaneously

Call #1 – hypotensive, shocky 67 yr old female in Mayerthorpe with perforated viscus. Through Red Patient Referral Process. Dispatch STARS-3 and gave rescuscitation advice to local doctor.

NG tube, fluids, Inotropic support, organized receiving surgeon

Helicopter dispatched and call from Wainwright EMS requesting scene RV with STAR-3

Initial Thoughts

Cardiac Arrest – dismal outcome, trauma arrest

CAF member – “full court press”

Similar efforts for RCMP, Fire, EMS, public safety

Then What ?ROSC of CAF mbr.

STARS Helicopter too far north

FW resources unable to land at Wainwright due to weather. Can only land in Lloydminster 1 hr away.

Both patients need Critical Care Transport to Tertiary Care expeditiously

Ground transport from Wainwright to Edmonton – 2 hrs with very inexperienced ground crew.

Physician accompaniment from Wainwright not possible.

What Transpired

Medical Care

TP called Wainwright Hospital, spoke to local physician

Appreciated that local physician needed help

Called local GP Anesthesia, who came in to help manage patient

What Transpired

Transport Medicine – Operational Aspects

No STARS, FW and Ground nonoptimum with current resources

Called CFB Edmonton Base Hospital – spoke to one of Flight Surgeons and he prepared to mobilize AE Team from ad hoc resources

Called RCAF 408 THS Flight Ops – rapid mobilization of Griffon with crew. FE reconfigured helicopter for Medevac

Spoke to Flt Surg to bring appropriate AE kit

Spoke to Wainwright Hospital to borrow ventilator, GP Anesthesia (was former Flt Surgeon)

Dispatched RCAF Helicopter to Wainwright Hospital with Ad Hoc AE team.

Provided ongoing TP OLMC to Flt Surg en route outbound, and at scene to prepare patient, inbound leg via text

Helipad at UAH needed to be secured and team prepared to receive at rooftop

Called UAH ED and prepared team, spoke to Trauma Team to prepare through Charge Nurse

Extreme Example

“massaging” the resources to meet the patient need

Physician role is “quarterbacking” patient journey

Active collaboration with Operational Coordinators to meet patient needs

Active real time support to caregivers in the field with minimal time delay

Summary

Physician as reluctant caregiver on commercial airliner

Physician as active member of aeroretrievalteam

Physician as “quarterback” of patient transport journey