Helicopter emergency medical service (HEMS) personnel are working in environments that may predispose them to stressful and traumatic events. However, the prevalence of posttraumatic stress and other mental health indica...Helicopter emergency medical service (HEMS) personnel are working in environments that may predispose them to stressful and traumatic events. However, the prevalence of posttraumatic stress and other mental health indicators in HEMS personnel is generally low. This study evaluated whether team cohesion may predict the prevalence of mental disorder symptoms. A total of 215 HEMS personnel from 6 Canadian provinces completed an online questionnaire measuring team cohesion and symptoms of posttraumatic stress and major depressive disorder. The results indicated that cohesion negatively predicted the prevalence of mental disorder symptoms. The findings imply that cohesion within teams is an important consideration in the management of mental health among HEMS personnel.
OBJECTIVE: Advanced airway management is a primary skill critical care transport teams provide. There are several measures of performance for airway management that can be tracked and improved through quality improvement...OBJECTIVE: Advanced airway management is a primary skill critical care transport teams provide. There are several measures of performance for airway management that can be tracked and improved through quality improvement initiatives. The purpose of this project was to improve first-pass intubation success rates and the associated Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) metric-definitive airway without hypoxia or hypotension. METHODS: A multiyear quality improvement initiative was undertaken. Best practices from the literature were identified and implemented through the Institute for Healthcare Improvement Model for Improvement using a plan-do-study-act cycle approach. Improvement cycles included airway training in a cadaver laboratory, implementation of an airway checklist, use of high-fidelity airway mannequins with simulation, and difficult airway mannequins that could be used for on-shift training. We prioritized tracking of first-pass intubation success rates with focused communication to the team. RESULTS: There was incremental improvement in first-pass success rates evidenced by the stepwise increase in annual moving averages starting at 59% and progressing to the current annual average at approximately 95%. Similarly, DASH-1A results exhibit similar incremental improvement in the moving annual average year on year, starting at 59% and improving to the current 92% annual average. CONCLUSION: Our results demonstrate that a dedicated quality improvement project focused on improving airway management, specifically first-pass success and DASH-1A, improved our transport team's performance over time.
OBJECTIVE: Medical evacuation with fixed-wing air ambulances and rescue helicopters plays an important role in Iceland's emergency medical services. The objective of this study was to measure the quality of physician-sta...OBJECTIVE: Medical evacuation with fixed-wing air ambulances and rescue helicopters plays an important role in Iceland's emergency medical services. The objective of this study was to measure the quality of physician-staffed fixed-wing air ambulance services in Iceland using the 15 response-specific quality indicators (QIs) developed by the EQUIPE consensus group in Scandinavia. METHODS: Physicians working in the Icelandic fixed-wing air ambulance service were asked to register response-specific QIs in an online questionnaire after every physician-staffed patient transport undertaken by the service from March 1 to December 31, 2023. RESULTS: The fixed-wing air ambulance service in Iceland did not reach the benchmarks proposed by EQUIPE in 11 of 15 QIs tested. Furthermore, 7 QIs fell in the low performance zone and 4 in the average performance zone. CONCLUSION: Sparse population density, long transports, and the lack of a single prehospital organizational structure are challenging for Icelandic physician-staffed emergency medical services. This is, to our knowledge, the first time that the quality of the service has been assessed from other perspectives than time and mortality alone. As a result, several areas in need of improvement have been identified in our study.
OBJECTIVE: This study aims to describe the epidemiology of critical care clinicians seeking careers in prehospital and retrieval medicine (PHRM) in Queensland. METHODS: This is a retrospective cohort exploratory analysis...OBJECTIVE: This study aims to describe the epidemiology of critical care clinicians seeking careers in prehospital and retrieval medicine (PHRM) in Queensland. METHODS: This is a retrospective cohort exploratory analysis of data from Queensland Health's 2023 Resident Medical Officer (RMO) Campaign, with subgroup analysis to demonstrate the demographics and interest from the Australasian College for Emergency Medicine (ACEM), College of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists (ANZCA), and Australian College of Rural and Remote Medicine (ACRRM). RESULTS: Of the applicants to Queensland's RMO Campaign, 32% had potential interest in a career in PHRM, with no statistical difference between the demographics of these groups. The median age of the applicants was 31 years, with ACRRM trainees having the youngest interested cohort. Furthermore, 68% trainees from core PHRM colleges were interested in PHRM, with ANZCA trainees having the lowest interest (52%) and ACEM having the highest (77%). CONCLUSION: There was significant interest in a career in PHRM, with ACEM trainees having the highest interest. There are significant differences in age, sex, and postgraduate study year in critical care colleges. As the PHRM field continues to evolve, understanding these demographic trends and training preferences is pivotal for fostering the growth of this subspecialty.
OBJECTIVE: Spontaneous coronary artery dissection (SCAD) refers to a naturally occurring tear or separation within the layers of the coronary artery walls. As a result, a blood-filled cavity forms within the coronary art...OBJECTIVE: Spontaneous coronary artery dissection (SCAD) refers to a naturally occurring tear or separation within the layers of the coronary artery walls. As a result, a blood-filled cavity forms within the coronary artery, obstructing blood flow to the myocardium. SCAD is an uncommon condition that predominantly affects young and healthy individuals, particularly women. METHODS: We performed a retrospective review of patients with a known or final diagnosis of SCAD transported for the years the electronic medical record was available (April 2017-November 2023). Given the descriptive and educational nature of this case series for quality improvement, with a small number of transports of interest, comparative statistics were not performed. RESULTS: We identified 30 patients with a coronary artery dissection undergoing 31 transports. Of these dissections, 2 were iatrogenic and 3 were associated with a concomitant aortic dissection, leaving 26 transports of 25 patients with SCAD. Of these patients, 20 were female (77%), and the median age was 51 (interquartile range 40.3-55.8) years. This skewed younger and more female than all adult transports, at 39.6% female with a median age of 62 (interquartile range 47-73) years. Seven (27%) of the transports involved a patient who was peripartum. In addition, 8 patients (31%) required mechanical circulatory support and 2 were on vasopressors. CONCLUSION: In a critical care transport registry, patients with SCAD were younger and more likely to be female than the general adult transport population. More than a quarter were peripartum, and 31% required mechanical circulatory support. Although rare, this is a high-acuity condition that affects a population traditionally considered to be less vulnerable to classic atherosclerotic coronary disease.
OBJECTIVE: Spontaneously breathing tracheostomy patients face unique challenges in maintaining adequate humidification of inspired gases due to the absence of natural humidification provided by the nasal passage and phar...OBJECTIVE: Spontaneously breathing tracheostomy patients face unique challenges in maintaining adequate humidification of inspired gases due to the absence of natural humidification provided by the nasal passage and pharynx. This systematic review evaluates the effectiveness of current humidification strategies to identify the best practices, aiming to better understand their potential application in low-humidity environments such as in air medical transport. In adult, spontaneously breathing tracheostomy patients, how effective are current humidification strategies-heat and moisture exchangers (HMEs), cool mist humidification (CMH), and heated humidifiers (HHs)-in maintaining adequate humidification and preventing complications? METHODS: A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, with a comprehensive search of PubMed, MEDLINE, Cochrane Library, and EBSCO databases for studies published between 2013 and 2024. The inclusion criteria were studies that involved spontaneously breathing tracheostomy patients and evaluated the effectiveness of humidification strategies, whereas exclusion criteria were studies on mechanically ventilated patients and pediatric population and reviews, editorials, and non-peer-reviewed articles. Data from the selected studies were extracted and assessed using the Cochrane risk of bias tool, the Newcastle-Ottawa scale, and an adapted CONSORT (Consolidated Standards of Reporting Trials) checklist for bench studies. A narrative synthesis was performed to summarize the findings due to the heterogeneity of study designs, interventions, and outcomes. RESULTS: A total of 6 studies were included in the review. These studies involved various humidification methods such as HMEs, CMH, and HHs. Results indicated that HMEs generally struggle to provide sufficient humidification, particularly when supplemental oxygen is required. CMH was generally less effective in maintaining adequate humidity levels, requiring more frequent tracheal suctioning due to inadequate humidification. HHs consistently provided the highest humidity levels and were the most effective in reducing respiratory complications and improving patient comfort, even with supplemental oxygen. CONCLUSION: The evidence included in this review is limited by the high risk of bias in some studies and the variability in study designs and methodologies. Although none of these studies specifically evaluated the effectiveness of humidification strategies in the unique environment of air medical transports, their findings suggest that the use of HHs is the most reliable method for maintaining adequate humidity levels. This review highlights the necessity of improving humidification strategies to ensure the comfort and safety of tracheostomy patients during air transport. Future research should focus on investigating the performance of different humidification methods in low-humidity environments, such as aircraft cabins, to address these challenges and improve patient outcomes.
OBJECTIVE: This review aims to enhance our understanding around whether neonatal air transport has an adverse physiological impact on patients. METHODS: A literature search included articles describing both ground and ai...OBJECTIVE: This review aims to enhance our understanding around whether neonatal air transport has an adverse physiological impact on patients. METHODS: A literature search included articles describing both ground and air transport. Eligible studies had to include patient outcome and/or response to the journey in such a way that the physiological impact of neonatal transport could be compared between the 2 groups. RESULTS: The search produced 13 eligible studies. Six were prospective observational cohort studies, and the remainder were retrospective. When assessing outcome, studies used a physiological stability score, the rate and severity of intraventricular hemorrhage, the type and frequency of clinical interventions during the journey, or a specific clinical parameter. Three of the studies sought to understand the physiological impact of transport by investigating the variation in the physical forces experienced. CONCLUSION: The current published evidence does not suggest one mode of transport is preferable to another when considering patient stability and outcome. Neonatal fixed wing or helicopter transport has not been shown to be more physiologically challenging for the patient than road transport, even by teams who are regularly flying patients in the highest-risk groups (extremely preterm, in the first hours of life).
OBJECTIVE: Nonshockable cardiac arrest rhythms have demonstrably poor outcomes. Pseudo-pulseless electrical activity (PEA), a subset of PEA in which visible cardiac contractility is present, is being described more frequ...OBJECTIVE: Nonshockable cardiac arrest rhythms have demonstrably poor outcomes. Pseudo-pulseless electrical activity (PEA), a subset of PEA in which visible cardiac contractility is present, is being described more frequently in recent literature. Physiology suggests that presence of cardiac motion even without a palpable pulse is energetically more favorable than true PEA, which is more like asystole. Therefore, we hypothesize that there is an increase in the survivability of PEA compared with asystole which may in part be due to a subset of pseudo-PEA. METHODS: A PICOST research question was generated which guided the composition of a systematic review and meta-analysis in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. RESULTS: A total of 494,355 patients were identified from 12 pieces of literature. Meta-analyses revealed an overall increased survivability of PEA compared with asystole (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.52-2.86). When differentiating between location of arrest, PEA was more survivable in both in-hospital cardiac arrest and out-of-hospital cardiac arrest than asystole (out-of-hospital cardiac arrest OR 4.17, 95% CI 3.78-4.60, and in-hospital cardiac arrest OR 1.60, 95% CI 1.42-1.79). Finally, when comparing neurological outcome of PEA with asystole, PEA was more favorable (OR 3.32, 95% CI 1.39-7.94). CONCLUSION: Pseudo-PEA may be one of the explanations attributed to better outcomes of PEA, especially neurological, due to the presence of cerebral and coronary flow. The presence of PEA likely requires evidence-based tailored management with presence of pseudo-PEA being more like a profound shock state. More evidence is required to investigate the true incidence of pseudo-PEA and its outcomes compared with true PEA.
Pulmonary arterial hypertension (PAH) is a unique disease process with a highly complex physiology. Patients with PAH are often on specialized medications that exert specific hemodynamic effects. Furthermore, when they b...Pulmonary arterial hypertension (PAH) is a unique disease process with a highly complex physiology. Patients with PAH are often on specialized medications that exert specific hemodynamic effects. Furthermore, when they become critically ill, the management strategy can be counterintuitive. Commonly accepted, evidence-based management for the general population, such as fluid boluses in the setting of sepsis, can be harmful to this patient cohort. Often, these patients require highly specialized care at tertiary and quaternary centers, which necessitates critical care transport. Therefore, it is important that critical care transport crews understand the distinctive pathophysiology and management of critically ill patients with PAH.
OBJECTIVE: This study retrospectively investigated the outcomes of patients with anaphylaxis transported by a staffed doctor helicopter (DH) using the keyword method, based on data from the Japan DH Registry System (JDRS...OBJECTIVE: This study retrospectively investigated the outcomes of patients with anaphylaxis transported by a staffed doctor helicopter (DH) using the keyword method, based on data from the Japan DH Registry System (JDRS). METHODS: Patients with anaphylaxis were selected from the JDRS database. Data collected included duration from first call to patient contact, patient demographics, vital signs, timing of DH dispatch request, medical interventions, duration of admission, and outcomes at 1 month. Subjects were divided into keyword (pre-contact) and control (post-contact) groups for comparison. RESULTS: Of 688 patients, all were evacuated from the scene, with no interhospital transports. There were no significant differences between the keyword (n = 430) and control (n = 258) groups with regard to age, sex, cardiac arrest on contact, vital signs, rate of medical intervention, and mortality rate. Duration of first call to contact and admission were significantly shorter in the keyword group. The keyword group also had a significantly higher ratio of good outcomes. CONCLUSION: To our knowledge, this study is the first to describe the keyword method as a prognostic factor in patients with anaphylaxis transported by DH. Adoption of the keyword method by firefighting central command rooms for the DH dispatch in anaphylaxis cases should be considered.
OBJECTIVE: Given the consequences of failed intubation, there is great interest in optimizing airway management success rates. Growing evidence suggests that use of a bougie device is associated with improved airway succ...OBJECTIVE: Given the consequences of failed intubation, there is great interest in optimizing airway management success rates. Growing evidence suggests that use of a bougie device is associated with improved airway success. Bougies with a flexible tip may increase intubation success by offering operators greater control. In this study, we performed a feasibility assessment of flexible tip bougies involving clinicians who routinely perform emergency airway management. METHODS: We used a feasibility simulation study design with pre- and postsurveys. Participants first completed a presession survey asking about their intubation experience and preferences. They were then given a brief demonstration of the flexible tip bougie with an opportunity to ask questions. They completed 2 intubations on an airway simulator using video laryngoscopy-one with a flexible tip bougie and one with a standard bougie. During these intubations, the time required to pass the bougie through the vocal cords and the time required to pass a tracheal tube through the vocal cords was assessed. Participants finally completed a postsession survey asking about their experiences with the flexible tip bougie. RESULTS: A total of 18 participants took part in the study. All participants rated themselves as familiar with tracheal intubation, and most (72.2%) said that they would consider using a flexible tip bougie on future intubations. Quantitatively, there was no clinically significant difference in the time needed to pass the bougie through the vocal cords (0.38 second) and the time needed to pass a tracheal tube through the vocal cords (8.24 seconds). CONCLUSION: Our simulation-based study comparing a flexible tip bougie with a conventional bougie revealed improved operator feedback with the flexible tip bougie and a clinically insignificant temporal difference in intubation metrics. Further study is needed to better assess the benefits of a flexible tip bougie in emergency and nonemergency airway management.
OBJECTIVE: Providing transparency on the state of selection processes in helicopter emergency medical services (HEMS) across different services is a vital step in developing universal standards for HEMS aircrew. This stu...OBJECTIVE: Providing transparency on the state of selection processes in helicopter emergency medical services (HEMS) across different services is a vital step in developing universal standards for HEMS aircrew. This study aimed to consolidate, rate, and evaluate information on selection processes from 9 HEMS across Australia and New Zealand. METHODS: This was a descriptive study combining objective and subjective assessment of selection to HEMS teams. Service leaders representing air medical services across Australasia participated in semistructured interviews to detail their selection processes. Selection assessments were then scored by independent subject matter experts (SMEs) using a predefined rating scale to evaluate characteristics of selection, including physiological intensity and task complexity. Furthermore, SMEs explored themes of service leaders' opinions on selection to HEMS teams. RESULTS: In evaluating the objective data in the context of service demographics, this study found that although job tasks were similar between services, selection processes and components differed significantly. However, qualitative exploration of service leaders' opinion on selection criteria, job tasks, and staff expectations closely aligned. CONCLUSION: This study finds shortcomings in the state of HEMS team selection processes and suggests a critical job task analysis at each service to verify the qualitative evaluations. These results may aid HEMS team leadership in developing evidence-based selection tests to ensure equitable and fair processes at their services, ensuring staff are suitable and safe to perform their critical roles.