OBJECTIVE: Organ transplantation is an operationally complex process. Centralized recovery centers (CRCs) address multiple logistical issues while decreasing costs and increasing organ transplanted per donor (OTPD). This...OBJECTIVE: Organ transplantation is an operationally complex process. Centralized recovery centers (CRCs) address multiple logistical issues while decreasing costs and increasing organ transplanted per donor (OTPD). This paradigm is predicated on the safe and effective transport of neurologically deceased donors from index facilities. Although the merits of CRCs are well studied, these transport processes have not been well assessed. We set out to evaluate the safety, feasibility, and efficacy of transporting brain-dead organ donors through air and ground critical care transport. METHODS: We completed a comprehensive review of our processes and retrospective chart review of all donor transports from index hospitals to the local CRC in an 18-month period. Clinical and transport data were both electronically and manually abstracted from 2 existing databases. RESULTS: Crews transported 74 donors (32 by air, 42 by ground) resulting in 257 organs transplanted (OTPD3.67). Median operating room time was 237 (interquartile range 205-292) minutes. Donors required a median of 2 (interquartile range 0-3) infusions and a mean norepinephrine equivalent of 0.02 µg/kg/min (standard deviation 0.06). One patient (1.4%) required blood products, 6 (8.1%) developed new hypotension, and 4 (5.4%) had new hypoxemia. There were no cardiac arrests in transport. CONCLUSION: Through a thoughtful collaboration between a busy organ procurement organization and well-established regional air and ground critical care transport service, in 18 months our system moved 74 donors from index hospitals to a new CRC for organ procurement. Our experience highlights the feasibility, safety, and efficacy of this cost-effective partnership.
OBJECTIVE: The health care industry accounts for 8.5% of US greenhouse gas emissions, with helicopter air ambulances (HAAs) contributing significantly. This study investigates the extent to which interfacility helicopter...OBJECTIVE: The health care industry accounts for 8.5% of US greenhouse gas emissions, with helicopter air ambulances (HAAs) contributing significantly. This study investigates the extent to which interfacility helicopter transfer interval affects patient outcomes, an essential consideration when optimizing flight paths. METHODS: We retrospectively analyzed adult HAA data from a large mid-Atlantic transport provider. Transport interval was defined as the time from dispatch to arrival at the receiving hospital. Patient diagnoses were categorized as cardiac, medical, neurological, surgical, and trauma. Discharge dispositions were grouped as home, hospice/morgue, and facility. Logistic regression analyzed discharge disposition as the dependent variable with transport interval and diagnostic category as independent variables. RESULTS: Analysis of 2,626 interfacility transfers revealed a significant logistic regression model (χ² = 202.67, df = 10, P < .001), explaining 4% to 8% of discharge variability. Although transport interval was a predictor (χ² = 45.32, df = 2, P < .001), the odds ratios (0.995 and 0.991) indicated negligible impact on outcomes. CONCLUSION: The weak association between transport interval and discharge outcomes suggests that small variations in interfacility transport interval could be allowed for when optimizing helicopter flight routes for efficiency. Optimization could reduce fuel consumption without negatively affecting patient outcomes.
OBJECTIVE: Low overhead height negatively affects chest compression performance. An adapted compression technique ("Koch") using an elbow has been evaluated. This study assesses longer duration and larger sample. METHODS...OBJECTIVE: Low overhead height negatively affects chest compression performance. An adapted compression technique ("Koch") using an elbow has been evaluated. This study assesses longer duration and larger sample. METHODS: A total of 52 first responders were paired and randomized to complete 12 minutes of Koch or conventional compressions on a Laerdal Resusci Anne manikin, alternating 2-minute cycles between partners. After rest, they crossed over. Primary outcomes were compression depth, recoil, landmarking, and overall quality score. Participant feedback was also collected. RESULTS: Results were significant. The mean quality compression score was 66.6% for Koch/28.3% for conventional (W = 348, P < .001, rrb = 0.98). Koch compressions increased mean depth by 18.8 mm (95% confidence interval 15.3-22.4). No conventional method result reached the target depth, whereas 58% (n = 15) of Koch compressions did. Correct mean release was different (W = 258, P = .011, rrb = 0.59); Koch at 43.4% versus conventional at 29.4%. Percentage of correct landmarking was different (W = 307, P < .001, rrb = 0.75); Koch at 89.0% versus conventional at 78.0%. Reported physical exertion and difficulty were lower for Koch compression (z = 6.042, P < .001) and described as easier and more sustainable. CONCLUSION: Despite minimal training, Koch compressions significantly outperformed conventional and was the preferred compression method in a height-restricted setting.
Hemorrhage is the leading cause of preventable early trauma death. Replacement of volume and clotting factors is a critical component to reduce morbidity and mortality. The objective of this rapid systematic review was t...Hemorrhage is the leading cause of preventable early trauma death. Replacement of volume and clotting factors is a critical component to reduce morbidity and mortality. The objective of this rapid systematic review was to evaluate the outcomes related to the administration of plasma in patients with traumatic hemorrhage in a prehospital environment. PubMed was searched for studies reporting plasma administration in prehospital patients with suspected traumatic hemorrhage. We reported each study's demographics, settings, and outcomes using the Prehospital Evidence-Based Practice Level and Direction of Evidence matrix. The search retrieved 1,008 titles, of which 43 articles were included. Most studies were randomized controlled trials or randomized controlled trial reanalyses, and the most common setting was critical care transport (CCT). Prehospital plasma was supported as the primary outcome of mortality in 73% of the studies. A total of 13 adverse events were reported across all studies, and plasma delivery was correlated with hypocalcemia in 1 study. High-quality evidence (Level and Direction of Evidence I) supports the delivery of plasma in the CCT prehospital setting to improvement of 30-day mortality for a range of patient presentations. The addition of plasma as part of a robust trauma resuscitation strategy in the CCT air medical setting is feasible and cost-effective.
Obstetrical care in the United States is in crisis. As timely access to obstetric care becomes increasingly less common in the United States, the role of an emergency medical services clinician in the care of a pregnant...Obstetrical care in the United States is in crisis. As timely access to obstetric care becomes increasingly less common in the United States, the role of an emergency medical services clinician in the care of a pregnant trauma patient has become increasingly important, particularly in rural or austere environments with extended times to arrival at a trauma center with capacity to provide definitive obstetrical care. In this review, we provide considerations for the primary management of pregnant trauma patients in a prehospital setting by reviewing the essentials of immediate care by organ system, with particular emphasis on airway support and medication considerations in pregnancy.
INTRODUCTION: Accurate tasking of physician-staffed prehospital critical care (PHCC) is crucial to best use this resource; however, there is mixed evidence regarding the efficacy of clinician-led dispatch. METHODS: Retro...INTRODUCTION: Accurate tasking of physician-staffed prehospital critical care (PHCC) is crucial to best use this resource; however, there is mixed evidence regarding the efficacy of clinician-led dispatch. METHODS: Retrospective cohort study of taskings for the emergency medical retrieval service, an air medical PHCC service in Scotland, between April 1, 2022 and October 31, 2022. The primary exposure was 1 of the following 3 dispatcher groups: PHCC clinicians, paramedics without PHCC designation, and nonclinical dispatchers. The number and characteristics of taskings were determined for each dispatch shift. Multivariable Poisson regression, including potential confounders, was used to determine the association between tasking group and count outcomes, multivariable linear regression-assessed associations with tasking time. RESULTS: In multivariable modeling, compared with nonclinical dispatch, PHCC clinicians dispatched the service 27.3% (95% confidence interval [CI] 3.5%-57.2%) more often, resulting in 28.6% (95% CI 0.0%-66.1%) more patient encounters. PHCC clinician call time was 18.6% (95% CI 4.7%-30.5%) shorter than nonclinical dispatchers. DISCUSSION: PHCC dispatch by PHCC clinicians is associated with higher numbers of dispatches and patient contacts and shorter call times. PHCC clinician dispatch has the potential to improve service tasking. Future research should consider not only the clinical status of dispatcher but also familiarity with PHCC.
Helicopter emergency medical services (HEMS) are pivotal in delivering rapid medical intervention to critically ill or injured patients. Since its establishment in Turkey in 2008, the HEMS network has expanded to 13 air...Helicopter emergency medical services (HEMS) are pivotal in delivering rapid medical intervention to critically ill or injured patients. Since its establishment in Turkey in 2008, the HEMS network has expanded to 13 air ambulances, enhancing health care accessibility in geographically challenging areas. However, the inaugural fatal HEMS accident on December 22, 2024, exposed significant operational vulnerabilities. This report meticulously evaluates the incident, focusing on contributory factors such as adverse weather conditions, human errors, and operational hazards. Drawing from international data and best practices, we propose evidence-based recommendations to bolster the safety and efficacy of HEMS operations in Turkey.
Patients with diabetic ketoacidosis (DKA) are at risk for adverse peri-intubation events. In severe metabolic acidosis, respiratory compensation with hyperventilation may already be maximized. During intubation, aggressi...Patients with diabetic ketoacidosis (DKA) are at risk for adverse peri-intubation events. In severe metabolic acidosis, respiratory compensation with hyperventilation may already be maximized. During intubation, aggressive apneic ventilation is required to mitigate the worsening acidemia and prevent cardiovascular collapse. Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apneic ventilation in which the ventilator delivers pressure-supported minute ventilation during preoxygenation and after the onset of paralysis, until laryngoscopy is attempted. In patients with DKA, VAPOX can be programmed to deliver high minute-volume ventilation during apnea to compensate for metabolic acidosis. This study describes the use of VAPOX during intubation in critically ill patients with DKA in a retrieval setting. We demonstrated the novel use of the Hamilton T1 ventilator in critical DKA physiology, a technique not yet reported in the DKA literature.
OBJECTIVE: Interfacility transports from lower-level health care facilities to specialized centers support regionalization of care and improve morbidity and mortality rates. We assessed the published literature related t...OBJECTIVE: Interfacility transports from lower-level health care facilities to specialized centers support regionalization of care and improve morbidity and mortality rates. We assessed the published literature related to neonatal transport costs and characterized the clinical and economic complexities of risk-based decision-making to inform health policy options. METHODS: We conducted a targeted scoping review of published ground and air transport literature reporting on cost-related outcomes with a focus on neonatal studies. We converted estimates to 2020 US dollars. We summarized methods, findings, and limitations of existing studies. From the perspectives of various stakeholders involved in complex transfer and transportation decisions, we provided simplified estimates of stakeholder cost scenarios and graphical representations of basic microeconomic concepts associated with transport. RESULTS: Eight cost-related neonatal transport studies were identified from different countries. The average estimated cost of ground transport was approximately $5,043 and $18,000 for air transport. Most cost-related studies used the perspective of the referring or accepting hospital, but not both. There were no randomized or experimental intervention studies. The literature suggests that the greatest portion of the costs incurred for transfers was for interhospital transports. Our simplified estimates illustrate trade-offs among distinct stakeholders for transport decisions. CONCLUSION: Interfacility transport decisions involve time-sensitive and complex processes affecting multiple stakeholders, with many variables beyond cost. Few studies report cost outcomes for neonatal transports, with identified studies varying by country-level health care systems, populations analyzed, study designs, and cost estimation methods. Improving the transport decision-making process may reduce patient risk and transport cost. Other strategies include expanding telehealth programs, improving communication among medical providers, strengthening specialist capacity at referring hospitals, and tailoring risk-based planning before delivery.
OBJECTIVE: This study focuses on airway management in offshore rescue helicopters, where patients often require initial and prolonged medical care during long flights. Here, the patient's atypical, sideway position in th...OBJECTIVE: This study focuses on airway management in offshore rescue helicopters, where patients often require initial and prolonged medical care during long flights. Here, the patient's atypical, sideway position in the helicopter cabin prevents intubation in the standard way. The aim of this study is therefore to investigate optimal strategies for airway management from the side. The results can also be transferred to other emergency situations with atypical patient position and confined spaces. METHODS: In a randomized trial, 440 intubations were performed on a manikin in 7 different settings, including the icepick method and video laryngoscopy (VLS). Primary outcomes were first-pass success (FPS) and intubation time. RESULTS: The standard supine position had the highest FPS (100% with VLS). Among alternative methods, kneeling sideways with VLS had the best FPS (94.5%, 100% on the second attempt) and shortest intubation time (14.6 ± 4.5 seconds). The icepick method without VLS had the lowest FPS (76.4%) and longest intubation time (34.0 ± 13.4 seconds). CONCLUSION: Sideway intubation using VLS is a viable alternative when standard positioning is not possible. The icepick method is not recommended due to lower success rates and prolonged intubation times. These findings have implications for airway management in confined and atypical environments.
OBJECTIVE: Search and rescue (SAR) endeavors to locate distressed persons in remote, challenging environments. The global surge in outdoor activities has increased SAR demand, prompting the need for efficient terrestrial...OBJECTIVE: Search and rescue (SAR) endeavors to locate distressed persons in remote, challenging environments. The global surge in outdoor activities has increased SAR demand, prompting the need for efficient terrestrial helicopter SAR operations. In South Africa, SAR practices face challenges due to a lack of standardization, governance, and clear guidelines, leading to communication and coordination issues. Standardized reporting and documenting frameworks are essential to ensure uniform practices, terminology, and documentation in helicopter SAR missions. This study focuses on the initial step of standardizing reporting and documenting terrestrial SAR to overcome these challenges and improve the quality of standardized report writing and documentation. METHODS: A modified Delphi survey was conducted in 3 rounds to obtain a sample criterion of variables for reporting and documenting terrestrial helicopter SAR operations. The first round of the Delphi study was informed by a literature review. Purposive snowball sampling was used to recruit experts in terrestrial rescue. An online survey tool offered both binary and free-text options to participants. The consensus rate was set to 75%. RESULTS: A panel of 28 participants agreed to participate in the study, and 16 (57%) completed all 3 rounds. A total of 65 items were proposed to the panel for review and were grouped into the following 5 categories: temporospatial, technical, operational, patient, and clinical. A consensus of 96.9% (63/65 items) was obtained during round 1, 77.5% (31/40 items) during round 2, and 33.3% (3/9 items) at the end of round 3. A total of 75 variables were included in the final list of items recommended for reporting terrestrial helicopter SAR operations. CONCLUSION: Standardized reporting enhances the efficiency, communication, and effectiveness of terrestrial helicopter SAR missions in South Africa. This study presents a comprehensive list of essential variables for reporting terrestrial helicopter SAR operations in South Africa.
OBJECTIVE: Stroke is a time-sensitive condition in which timely intervention is crucial for optimal outcomes. Advances in stroke management, including extended time windows for thrombolysis and mechanical thrombectomy, h...OBJECTIVE: Stroke is a time-sensitive condition in which timely intervention is crucial for optimal outcomes. Advances in stroke management, including extended time windows for thrombolysis and mechanical thrombectomy, highlight the need for efficient patient centralization. This study explores the newly adopted stroke algorithm for patient centralization in Lombardy, Italy, and evaluates the potential for helicopter emergency medical services (HEMS) to improve access to timely care. METHODS: Data regarding stroke rescue missions were retrieved from SAS-AREU database. Geospatial maps were created using QGIS (Open Source Geospatial Foundation (OSGeo), Chicago, IL) 3.30, with travel times calculated using Google Maps data. Population density was retrieved from Geoportal Lombardia. Area with road travel time to a Hub hospital >60 minutes were identified as potential HEMS priority settings. RESULTS: In 2024, 11,822 patients rescued by the Regional Agency for Emergency and Urgency were given the "stroke code." HEMS was used in 214 cases, covering a median distance of 49.3 km with a median rescue time of 77 minutes. The study identified areas with road travel times exceeding 60 minutes, highlighting northern Lombardy's mountainous regions and areas with low population density as high priority areas for HEMS intervention. The analysis also revealed an unexpected advantage for air transport in some plain areas, despite viable road access. CONCLUSION: Geospatial mapping is a valuable tool for identifying areas where HEMS can reduce response times. The integration of HEMS into stroke care algorithms enhances timely interventions, ensuring that patients are centralized within recommended time windows, improving outcomes, and addressing geographic and infrastructural challenges.
OBJECTIVE: The transport of sick newborn infants with respiratory distress leads to unwanted stress at time of physiological instability. There is dearth of studies to evaluate these stress levels. This pilot prospective...OBJECTIVE: The transport of sick newborn infants with respiratory distress leads to unwanted stress at time of physiological instability. There is dearth of studies to evaluate these stress levels. This pilot prospective observational before-after study aimed to evaluate the plasma cortisol levels (as surrogate marker of stress) in infants with respiratory distress during different phases of neonatal transport. METHODS: Plasma cortisol was measured before transport, on arrival at tertiary hospital, and after 48 hours. Perinatal demographics and retrieval and disease characteristics were collected from neonatal transport and neonatal intensive care unit records. Neonatal transport factors that may affect the cortisol response were also evaluated. RESULTS: A total of 55 infants were recruited, of which 40 infants who had cortisol levels measured in all the 3 phases of neonatal transport were included in the final analyses. Median (interquartile range) cortisol levels measured before transport, on arrival at tertiary hospital, and after 48 hours were 520 (250-770) nmol/L, 315 (172.5-520) nmol/L, and 125 (70-250) nmol/L. There was a reduction in the paired median cortisol levels between the sample taken before transport and arrival at a tertiary hospital by 24% (P = .048) and at 48 hours by 73% (P < .001). Gestational age, gender, duration of respiratory support, and transport duration did not alter the change in cortisol levels. CONCLUSION: Neonatal transport does not seem to influence the anticipated fall in plasma cortisol levels post-birth in infants with respiratory distress. Future studies with larger sample size using both behavioral and physiological parameters for stress evaluation in neonatal transport are warranted.
OBJECTIVE: Pediatric critical care transport (PCCT) teams are expected to manage a wide spectrum of pediatric high-acuity conditions. PCCT program leaders may have unique insights into transport team training, including...OBJECTIVE: Pediatric critical care transport (PCCT) teams are expected to manage a wide spectrum of pediatric high-acuity conditions. PCCT program leaders may have unique insights into transport team training, including opportunities, experiences, and barriers. The purpose of this study was to understand how PCCT program leaders perceived the role of simulation in PCCT team education. METHODS: PCCT medical directors or administrators from 12 ImPACTS (Improving Pediatric Acute Care Through Simulation) sites were recruited to participate in a 30-minute interview with trained facilitators. A semistructured 7-question interview guide on the barriers, supports, and opportunities presented by transport simulations was used. Interviews were digitally recorded, and transcripts were organized using Dedoose qualitative software. A grounded theory approach was used to identify themes. RESULTS: A total of 11 interviews were conducted with 5 PCCT medical directors (45%) and 6 administrators/clinical managers (54%) from 11 participating ImPACTS health facilities. Themes on participant experience with simulation, simulation feeling real, value of simulation, planning simulations, and logistical challenges were identified. CONCLUSION: In general, although PCCT program leaders acknowledge logistical difficulties with planning simulations, they feel that transport simulations, particularly conducted in situ in a transport vehicle, are a helpful educational tool for PCCT teams.