OBJECTIVE: In Norway, helicopter emergency medical services (HEMS) are dispatched for suspected cerebral stroke if intravenous thrombolysis may be administered within 4.5 hours of symptom onset, and it reduces time of tr...OBJECTIVE: In Norway, helicopter emergency medical services (HEMS) are dispatched for suspected cerebral stroke if intravenous thrombolysis may be administered within 4.5 hours of symptom onset, and it reduces time of transport by ≥30 minutes compared with basic emergency medical services (EMS). However, cerebral stroke presents with heterogeneous symptoms; therefore, identification by emergency dispatchers can be difficult. The primary outcome was the positive predictive value for stroke among patients with suspected stroke for whom HEMS was dispatched. Secondary outcomes included rates of prehospital interventions, quality indicator fulfillment, and rates of selected in-hospital interventions within time limits. METHODS: We conducted a retrospective cohort study using aggregated prehospital and in-hospital data from an electronic patient journal. It included 161 primary missions from the HEMS base in Trondheim, where HEMS was deployed on the index criterion of cerebral stroke set by the Emergency Medical Coordination Center between 2022 and 2024. RESULTS: Of all primary missions, 14% (n = 162) were because of suspected stroke. A total of 75 patients (47%) were diagnosed with having stroke, whereas 12 (7%) were diagnosed with having transient ischemic attack. In 7% of cases, an advanced intervention that requires a physician was performed. A total of 40 patients (25%) received intravenous thrombolysis and/or endovascular thrombectomy. CONCLUSION: Stroke was confirmed in 47% of HEMS dispatches for suspected stroke. HEMS likely reduced transport time by ≥30 minutes for most patients, whereas prehospital advanced interventions were rarely performed. Further studies on index use and comparative studies of HEMS and EMS dispatches could help strengthen patient selection and optimize resource utilization.
OBJECTIVE: Determining patient acuity before interfacility transport allows for better use of assets and personnel if it can be done accurately and reliably. We developed an acuity matrix to be used at the time of dispat...OBJECTIVE: Determining patient acuity before interfacility transport allows for better use of assets and personnel if it can be done accurately and reliably. We developed an acuity matrix to be used at the time of dispatch and sought to validate it against actual findings upon patient contact and compare dispatcher and flight crew determinations. METHODS: Lifeguard is a public, not-for-profit, university-owned, fixed-wing, rotor-wing, and ground transport agency. Lifeguard has its own communications center staffed by paramedics. At the time of call intake, before crew notification, our dispatchers recorded their determination of acuity. After dispatch, but before departure, the flight crew recorded their determination of acuity. After completion of the transport, the flight crew recorded the final determination of acuity. Results were compared using Gwet's agreement coefficient (AC) with quadratic weighting. RESULTS: The matrix was implemented in April 2023. Between April 2023 and September 2023, there were 825 total dispatches and 674 with complete data. Dispatchers had excellent agreement (89.1%) with the medical crew on initial tier assignment (Gwet's AC, 0.96; 95% confidence interval [CI], 0.94-0.97) with 5.7% overtriage and 5.2% undertriage. Dispatchers also had excellent agreement (85.9%) with final acuity (Gwet's AC, 0.94; 95% CI, 0.93-0.96); they overtriaged 6.7% and undertriaged 7.4%. Medical crew had excellent agreement (92.9%) with final acuity (Gwet's AC, 0.97; 95% CI, 0.96-0.98); they overtriaged 4.3% and undertriaged 2.9%. CONCLUSION: Flight crew and paramedic dispatchers can accurately and consistently determine patient acuity based only on dispatch information with outstanding agreement. This tool may have a role in triaging multiple transport requests, assigning the appropriate asset and personnel, determining when it is reasonable to expect crew to stay over time, and conducting utilization review.
OBJECTIVE: Previously, young children had limited respiratory support options during interfacility transport. Recently, high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) have become available for pediatric...OBJECTIVE: Previously, young children had limited respiratory support options during interfacility transport. Recently, high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) have become available for pediatric transport. We hypothesized that the implementation of HFNC and NIV on interfacility transport decreases the rate of intubation in infants and toddlers before and after transport to a tertiary-care pediatric intensive care unit (PICU). METHODS: We conducted a retrospective chart review of children aged 30 days to < 36 months transported to a tertiary-care PICU from a referring hospital with respiratory distress from 2014 to 2019. Groups were analyzed before (2014-2017) and after the implementation (2017-2019) of HFNC and NIV during transport. NIV was defined as positive pressure ventilation delivered through nasal cannula. The primary outcome was to compare the pre- and postimplementation groups with regard to the rate of intubation before transport and within 48 hours of PICU admission. Secondary outcomes were the association between intubation rate and comorbidities and the comparison of length of respiratory support and hospital length of stay between the pre- and postimplementation groups. RESULTS: A total of 262 patients met criteria, 133 before and 129 after the intervention. The rate of intubation before PICU admission was 44% in the preintervention group versus 36% in patients transported after the implementation of HFNC and NIV, a trend that was not statistically significant (P = .19). The rate of intubation within 48 hours of PICU admission was 8% (before) and 11% (after) with no statistical significance (P = .48). Comorbidities were not associated with an increased rate of intubation before transport (P = .09) or within 48 hours of admission (P = .45). Hospital length of stay and length of respiratory support were not different between pre- and postintervention groups (P = .18 and P = .3, respectively). The availability of HFNC/NIV was associated with a significant decrease in the proportion of patients who received oxygen via nasal cannula or face mask during transport (46% before vs. 13% after the intervention; P < .01). CONCLUSION: After the introduction of HFNC/NIV during transport to a large tertiary-care hospital in a major metropolitan area, fewer nasal cannula/face masks were used during transport in favor of HFNC/NIV but no significant change in intubation rates was found.
OBJECTIVE: Decreased time to cardiac catheterization improves survival and limits cardiac tissue damage in ST Elevation myocardial infarction (STEMI). Emergency medical services delays account for half of treatment delay...OBJECTIVE: Decreased time to cardiac catheterization improves survival and limits cardiac tissue damage in ST Elevation myocardial infarction (STEMI). Emergency medical services delays account for half of treatment delays in STEMI. Helicopter air ambulance (HAA) can reduce the time to percutaneous intervention (PCI), and therefore may reduce mortality. The impact of physical distance between the PCI hospital helipad and the PCI laboratory on the door-to-door-to-balloon time (DDBT) for cardiac intervention in STEMI patients transported through HAA from remote community hospitals to PCI facilities was assessed. METHODS: This was a retrospective chart review of interfacility STEMI patients where HAA was activated to reduce DDBT from January 1, 2020, to January 1, 2023. The HAA agency under review transports STEMI patients to 2 PCI centers. There is a significant difference in the distance between the helipad and the PCI laboratory at the 2 hospitals. Descriptive statistics were used to compare DDBT as well as the time from HAA arrival at the PCI hospital helipad to the cardiac catheterization laboratory. RESULTS: Data were available for 91 STEMI cases. The median time for DDBT was 89.9 minutes with a median time of 10.5 minutes from helipad arrival to catheterization laboratory (Table 1). Of the 91 cases, 69 (76%) were from hospital A and 22 (24%) were from hospital B. There was no detectable difference in the distribution of DDBT times between hospitals (P = .47). Helipad arrival times to cardiac catheterization laboratory were significantly longer for hospital A than hospital B (P < .001). The median time for hospital A was 11.0 minutes (interquartile range, 9.2-14.0) compared with hospital B, which had a median of 5.4 minutes (5.0-7.3). CONCLUSION: The physical distance a PCI laboratory is located from the helipad can be a significant addition to ischemic time for STEMI patients.
Evidence supporting the use of sugammadex as a rescue strategy in prehospital "cannot intubate, cannot oxygenate" (CICO) situations remains sparse and indirect. Although contemporary airway guidelines prioritize front-of...Evidence supporting the use of sugammadex as a rescue strategy in prehospital "cannot intubate, cannot oxygenate" (CICO) situations remains sparse and indirect. Although contemporary airway guidelines prioritize front-of-neck access (FONA) as the definitive intervention, discussion of pharmacological reversal persists in prehospital practice, predominantly within gray literature, local protocols, and educational materials. This persistence reflects an ongoing hypothesis in prehospital airway management that warrants critical appraisal. We performed a narrative synthesis of perioperative, emergency department, and prehospital literature, including case reports, expert consensus documents, and contemporary airway guidelines, to assess whether pharmacological reversal can plausibly modify outcomes in airway failure. Across these sources, no outcome-level data support sugammadex as an effective rescue maneuver in established CICO. Perioperative CICO case series further indicate that reversal of neuromuscular blockade does not reliably resolve airway obstruction or obviate the need for surgical airway access. In the prehospital environment, rapid desaturation and limited monitoring further reduce the plausibility of pharmacological rescue once CICO has developed. For helicopter and ground emergency medical service systems, current evidence supports emphasis on early recognition of CICO, structured airway algorithms, and timely performance of FONA, rather than reliance on pharmacological reversal.
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, mandates that individuals presenting with emergency medical conditions receive appropriate screening, stabilizing treatment, or transfer-regardless...The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, mandates that individuals presenting with emergency medical conditions receive appropriate screening, stabilizing treatment, or transfer-regardless of their ability to pay or mode of transport. As EMTALA approaches its 40th anniversary, recent legal developments, including the Idaho and Moyle cases, have tested its federal preemption and implications for emergency medical transfers. This article evaluates evolving enforcement, regulatory shifts, and operational impacts on air medical services. It highlights compliance risks, reimbursement pressures, and best practices for air medical providers navigating a complex legal landscape. The analysis underscores EMTALA's enduring role in safeguarding emergency care and the need for coordinated legal and clinical strategies in air medical transport.
Advanced prehospital care delivered by air ambulance services in the United Kingdom aims to reduce preventable trauma deaths by bringing hospital-level interventions directly to patients. Despite these efforts, a signifi...Advanced prehospital care delivered by air ambulance services in the United Kingdom aims to reduce preventable trauma deaths by bringing hospital-level interventions directly to patients. Despite these efforts, a significant proportion of patients still die in the immediate phase, and current learning frameworks focus predominantly on identifying errors rather than examining all fatalities for system-wide improvements. This paper explores the potential of integrating multidisciplinary approaches, particularly clinicopathological correlation (CPC) meetings, into high-performing air ambulance services to enhance learning from every death. By including autopsy pathologists alongside clinicians, CPC meetings provide a robust platform to correlate prehospital findings with definitive postmortem results, improving diagnostic accuracy, clinical reasoning, and professional development. They also foster interprofessional collaboration, support clinician well-being by providing closure, and strengthen patient safety through contextualized learning beyond fault finding. Barriers include limited data sharing, coronial processes, and inconsistent governance across independent air ambulance services. However, the successful implementation of CPC multidisciplinary team meetings demonstrates significant educational and systemic benefits, driving innovation, and quality assurance. We propose that all high-performing air ambulance services should adopt structured, regular CPC meetings with pathologist involvement, thereby embedding learning from every fatality as a cornerstone of governance, resilience, and future improvements in care.
Patients seek planned health care outside of their home country for several reasons, one being that the treatment of choice might not be legally available in their respective place of residence (eg, abortion of pregnancy...Patients seek planned health care outside of their home country for several reasons, one being that the treatment of choice might not be legally available in their respective place of residence (eg, abortion of pregnancy, assisted dying/suicide, gender transition). The practice of traveling abroad with the intention of participating in a health-related activity that is prohibited in one's own country but not in the destination country has been coined as circumvention. In the context of international medical transportation, someone who assists a person in accessing a procedure that is illegal in the person's home country, state, or jurisdiction may face significant legal consequences for facilitating a criminal act under domestic law, even if that act is not committed in the country in which it is illegal. Commercial entities engaging in international medical transportation are well advised to protect their employees and organizations from these substantial legal risks by thoroughly investigating the legal and ethical background of cross-border transports to or from treatments that are not legally available in the country of patient origin or destination. Patients who cannot travel independently may be exposed to a disadvantaged and potentially harmful situation.
OBJECTIVE: Congenital diaphragmatic hernia (CDH) occurs when a diaphragmatic defect develops in utero, allowing herniation of the abdominal contents into the chest cavity. As a result, many neonates with CDH are critical...OBJECTIVE: Congenital diaphragmatic hernia (CDH) occurs when a diaphragmatic defect develops in utero, allowing herniation of the abdominal contents into the chest cavity. As a result, many neonates with CDH are critically ill after birth owing to varying degrees of pulmonary hypoplasia, respiratory failure, pulmonary hypertension, and cardiac dysfunction. Neonates with CDH require surgical repair of the diaphragmatic defect, and those who are not born at a center with the ability to perform pediatric surgery must be transferred to one shortly after birth. Our objective was to describe transport characteristics and vital sign variability for neonates with CDH transferred after delivery. METHODS: This was a retrospective observational analysis of 51 neonates with prenatally diagnosed CDH born at a single delivery hospital between March 2020 and March 2024 and transported to a single tertiary referral neonatal intensive care unit. Descriptive statistics were used to compare groups by CDH severity. RESULTS: Neonates with severe CDH were transported more rapidly than those with mild or moderate CDH. During transport, more neonates with severe disease received inhaled nitric oxide, but other transport interventions were not significantly different between the groups. All neonates experienced at least 1 abnormal vital sign. A higher proportion of neonates with severe CDH had low oxygen saturation values compared with those with milder disease. CONCLUSION: Vital sign abnormalities were universally common during transport, highlighting the physiologic instability of neonates with CDH. Understanding these transport variables will aid provider teams in decision making for these critically ill neonates.
OBJECTIVE: Critical hemorrhage is a life-threatening condition in which blood transfusion is an essential lifesaving intervention. Although the importance of prehospital blood transfusion is increasingly recognized, its...OBJECTIVE: Critical hemorrhage is a life-threatening condition in which blood transfusion is an essential lifesaving intervention. Although the importance of prehospital blood transfusion is increasingly recognized, its effectiveness remains unclear, particularly in Asian health care settings. This study aimed to characterize patients receiving prehospital blood transfusion through helicopter emergency medical services (HEMS) and evaluate their association with survival outcomes in a Japanese population-based cohort. METHODS: We conducted a retrospective evaluation of data from the Japanese Society for Aeromedical Services Registry from April 2020 to March 2023. This study included adult patients transported by physician-staffed HEMS. Propensity score matching (1:4) was used to adjust for confounding factors. The primary outcome measure was patient survival until hospital discharge. RESULTS: Among the 24,776 patients, 71 (0.3%) received prehospital blood transfusions using type O packed red blood cells. Transfusion recipients had lower systolic blood pressures (83 mm Hg vs. 138 mm Hg; P < .001) and higher rates of external causes of injury (80.3% vs. 51.1%; P < .001) than did those who did not receive a transfusion. After propensity score matching (N = 230), prehospital transfusion was associated with improved survival (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.05-4.18). The results of the trauma subgroup analysis showed no statistically significant association (OR, 1.88; 95% CI, 0.80-4.40). CONCLUSION: In Japan's physician-staffed HEMS, prehospital blood transfusion was appropriately provided to patients with hemorrhagic shock and, after adjustment for confounding factors, was associated with improved survival. These findings provide evidence supporting the potential benefits of prehospital blood transfusion in appropriately selected patients within physician-staffed air medical systems.
OBJECTIVE: Powered 2-wheeler (PTW) riders are a highly vulnerable road-user group who frequently require helicopter emergency medical services (HEMS) for critical care and transport. This study aimed to describe the popu...OBJECTIVE: Powered 2-wheeler (PTW) riders are a highly vulnerable road-user group who frequently require helicopter emergency medical services (HEMS) for critical care and transport. This study aimed to describe the population of injured PTW riders attended by the Danish Air Ambulance and compare them with the wider Danish HEMS trauma population. METHODS: This was a retrospective population-based study of Danish HEMS missions from January 1, 2018, to December 31, 2023, including all primary missions involving a PTW patient. Data were collected from the Danish HEMS database on patient demographics, vehicle type, interventions performed, and destination. We also registered International Classification of Diseases, 10th edition, diagnoses and National Advisory Committee for Aeronautics (NACA) scores. RESULTS: A total of 228 patients (90% male) were included. The most common diagnosis was unspecified multiple injuries (49%), indicating polytrauma. Significant differences were noted between vehicle types: 58% of injured motorcyclists were involved in accidents with another vehicle, whereas 59% of scooter rider incidents were single vehicle. Notably, 67% of PTW patients were assigned a NACA score of ≥4, and 71% required at least 1 prehospital intervention. Most were transported to a major trauma center (MTC) (85% of motorcyclists vs. 76% of scooter riders). Compared with the general Danish HEMS trauma population, PTW patients had higher NACA scores, were more likely to be conveyed to MTCs, and more frequently required prehospital interventions. CONCLUSION: PTW riders attended to by the Danish Air Ambulance represent a severely injured patient cohort who more frequently require advanced prehospital treatment and transport than the wider trauma population.
OBJECTIVE: Trauma patients often present to emergency departments with coagulopathies. Recognizing the unique challenges of caring for trauma patients and the urgent need for protocol-driven resuscitation is essential. M...OBJECTIVE: Trauma patients often present to emergency departments with coagulopathies. Recognizing the unique challenges of caring for trauma patients and the urgent need for protocol-driven resuscitation is essential. METHODS: This project used a practice evaluation design that incorporated simulation-based learning (SBL) to educate critical care transport team (CCTT) providers on the existing whole blood administration protocol (WBAP), aiming to enhance protocol adherence and staff preparedness. RESULTS: Most participants (77%) successfully adhered to all critical decision points, indicating notable improvements in adherence. Participants reported increased confidence, knowledge, and preparedness following SBL, each with a mean of 2.9 and a median of 3.0, where 1 = do not agree, 2 = somewhat agree, and 3 = strongly agree. Simulation reinforced critical decision-making (mean 3.0) and procedural skills (mean 2.9), aligning with established best practices. CONCLUSION: SBL improved trauma care training, reinforced critical decision-making, and strengthened procedural skills among CCTT providers. Further research is needed to assess multiple aspects of the WBAP during critical care transport missions and the long-term sustainability of educational interventions. Ongoing training, policy enhancements, and continued whole blood use in CCTT care may contribute to improved outcomes for trauma patients.
OBJECTIVE: The breadth and complexity of care in the out-of-hospital environment are increasing. The clinical decision-making process of emergency medical services clinicians is not well understood. METHODS: This study a...OBJECTIVE: The breadth and complexity of care in the out-of-hospital environment are increasing. The clinical decision-making process of emergency medical services clinicians is not well understood. METHODS: This study aimed to analyze the process of critical care transport clinicians using simulated scenarios with structured debriefing. Members of a critical care transport team completed a simulation session during which they cared for a medical or trauma patient with airway management concerns. A standardized debriefing exploring their decision-making process was performed after the simulation session, recorded, and transcribed. Thematic analysis was performed to uncover themes related to the clinical decision making that took place. RESULTS: A total of 8 subjects (5 nurses and 3 paramedics) completed simulation sessions including 5 medical and 3 trauma scenarios. The median years of experience in critical care transport was 15. The following 3 themes emerged from the quantitative analysis: (1) participants felt that the scenarios were realistic and applicable to their daily practice, (2) participants felt that the scenarios required them to think critically, and (3) participants relied on established protocols combined with experience for their clinical decision making. CONCLUSION: During the simulated care of complex patients with airway management concerns, critical care transport clinicians made complex decisions by using a combination of standing protocols, experience, and foundational knowledge.
BACKGROUND: Endotracheal intubation of trauma patients incurs risks including post-intubation hemodynamic collapse. Trauma patients are at increased risk of secondary harm related to hypotension. The aim of this study wa...BACKGROUND: Endotracheal intubation of trauma patients incurs risks including post-intubation hemodynamic collapse. Trauma patients are at increased risk of secondary harm related to hypotension. The aim of this study was to describe post-intubation hemodynamic collapse in traumatically injured CCT patients and investigate associations with in-hospital outcomes. METHODS: Retrospective chart review of trauma patients ≥18 years admitted to a rural level one trauma center who were transported and intubated by the hospital-based CCT service between January 2017 and June 2024. Hemodynamic collapse was defined as cardiac arrest, systolic blood pressure (SBP) <65 mmHg at least once, SBP <90 mmHg for greater than 30 minutes, new vasopressor requirement, vasopressor dose increase, or fluid bolus of >15 mL/kg to maintain SBP. The primary outcome was the incidence of hemodynamic collapse. Secondary outcomes were identification of potentially modifiable patient risk factors and in-hospital outcomes including length of stay and mortality. RESULTS: One hundred forty-two trauma patients were included. Thirty-five (24.6%) patients experienced hemodynamic collapse and 2 (5.7%) had cardiac arrest. When controlled for ISS, patients with pre-intubation blood administration (OR 5.89, 95% CI 1.8-19.31), pre-intubation vasopressors (OR 11.21, CI 2.02-62.25), and first systolic blood pressure <90 mmHg (OR 7.66, CI 1.18-49.74) had higher odds of hemodynamic collapse after intubation. The median shock index and injury severity scores (ISS) were also higher: 1.07 (0.71-1.38) versus 0.68 (0.53-0.84) and 36 (14-43) versus 24 (17-34), respectively (p <0.05). When controlled for ISS there was no significant difference in hospital mortality (OR 1.78, 95% CI 0.73-4.36). CONCLUSION: Post-intubation hemodynamic collapse occurred in 1 in 4 patients in this cohort of traumatically injured patients. Patients with post-intubation hemodynamic collapse were more likely to have received blood, fluids, and vasopressors and they had higher ISS and in-hospital mortality. The risks and benefits of a definitive airway for these patients must be carefully weighed.
OBJECTIVE: Airway management in profoundly unstable patients, particularly those in a peri-arrest state, remains a contentious issue in out-of-hospital environments. Although there is robust literature on advanced airway...OBJECTIVE: Airway management in profoundly unstable patients, particularly those in a peri-arrest state, remains a contentious issue in out-of-hospital environments. Although there is robust literature on advanced airway procedures for acutely ill patients, literature on prehospital patients in profound shock is sparse. This study represents a survey-based analysis of critical care transport medicine (CCTM) experts to describe the challenges and strategies for intubating patients with significant hemodynamic instability. METHODS: Before the Air Medical Physician Symposium (AMPS) Lite, an online exploratory survey was developed from a convenience sample of AMPS attendees regarding best practices, knowledge gaps, barriers to translation, and research priorities. AMPS featured educational lectures and discussions on critical care transport topics, including definitive airway management for patients in profound shock. Participants included CCTM experts from a variety of programs across the United States and internationally. The symposium included expert panel discussions and audience ranking of these categories using electronic voting. RESULTS: The survey-based analysis highlighted the importance of understanding the physiological and pharmacological principles surrounding rapid sequence intubation and other intubation strategies. Rankings emphasized the need for research on shock dosing of sedatives and the potential for paralytic-only intubation in profoundly obtunded patients. CONCLUSION: The study concluded that further investigation is needed to develop evidence-based guidelines for intubating patients in profound shock. The findings suggest that reduced sedation dosing and consideration of using paralytic-only intubation may mitigate the risks of cardiovascular collapse and improve patient outcomes in this critically ill patient population.