Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study.

OBJECTIVE: Interhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. METHODS: This was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. RESULTS: A total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. CONCLUSION: Geographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

Prehospital Echocardiogram Use in Identifying Massive Pulmonary Embolism in Unidentified Respiratory Failure.

Medical transport teams often handle cases of complex, critically ill patients and are in need of rapid, bedside assessments to guide clinical decision making. The use of point-of-care ultrasound (POCUS) as a diagnostic indicator has gained increased acceptance in emergency medicine. Ultrasound devices have become increasingly portable, and numerous studies have demonstrated that use in the prehospital setting is feasible, accurate, and can have a dramatic impact on the care of patients. In this case report, we highlight the use of handheld ultrasound in the identification of right heart dilation in an unstable patient with respiratory failure in a rural emergency department, concerning for massive pulmonary embolism. The patient was given thrombolytic therapy with dramatic clinical improvement, ultimately surviving transport to the intensive care unit at a nearby tertiary care center.

Tranexamic Acid Use in Pediatric Hemorrhagic Shock From Farm-Related Trauma: A Case Report.

This case describes the use of tranexamic acid as an adjunctive treatment in the management of a pediatric patient in hemorrhagic shock. The case also highlights other components of current best practices for hemorrhagic shock in children, including bleeding source control and prompt resuscitation with blood products. A 20-month old male suffered an agricultural accident with significant injury to the right upper extremity. This led to subsequent extremity hemorrhage and clinical evidence of hemorrhagic shock. As a result of interventions performed by emergency medical services as well as the helicopter emergency medical services team, including the application of a tourniquet, prehospital blood product administration, and tranexamic acid administration, the patient had hemodynamically stabilized by arrival at the level 1 pediatric trauma center and was neurologically intact when discharged from the hospital.

A Model Curriculum for a Helicopter Emergency Medicine Services (HEMS) Rotation for Resident Physicians.

Audience: This curriculum is designed for resident physicians at all levels of training who have an interest in HEMS. Length of Curriculum: This curriculum is designed to run over a 28-day period. Introduction: Helicopter emergency medicine services play a critical role in patient transport, and resident physicians may often encounter patients transported by HEMS programs. Residents, and emergency medicine residents in particular, are being offered more opportunities to gain flight experience with HEMS programs; however, these experiences may be highly variable. These inconsistencies in training experiences may lead to incomplete understanding of HEMS systems and patient care performed during flight. Educational Goals: The primary objective of this course is to present a standardized curriculum which allows learners to gain understanding of HEMS systems and retrieval medicine while practicing safety in the aviation environment. Educational Methods: The educational strategies used in this curriculum include hands-on training with senior flight staff, asynchronous learning via access to a curated reading "library," and in-person learning via ride-along experience on the aircraft and program operational meeting attendance. Research Methods: This curriculum was introduced at the authors' institution and was completed by 11 rotating resident physicians, primarily PGY-2 and PGY-3 emergency medicine residents. Learners completed free-form feedback forms as well as a numerically graded post rotation survey. Learner feedback was used to identify areas where additional instruction was necessary and make changes to optimize learner flight experience. Results: The curriculum was graded by learners on a 5-point Likert scale. The statement of "My overall educational experience during the rotation met my expectations and the learning objectives outlined at the beginning of the rotation" received an average score of 4.7 based on 1-Disagree to 5-Completely agree. The statement "The longitudinal curriculum contributed to my learning" averaged 4.5. A score of 4.9 was given for the statement "I found the rotation to be of use in my emergency medicine training." Free-form feedback was also solicited by learners and included comments such as "It was helpful for me to spend some time in the airway [and procedure] lab and go through the shift topics." Discussion: As evidenced by the learner feedback and survey results, the curriculum was effective in meeting the designed educational objectives, and learner feedback was largely positive in nature. Utilizing dedicated daily teaching topics was key to providing a standardized learning experience and ensuring that education progressed without reliance on flight call volumes. Topics: Helicopter aviation safety, HEMS crew member operations, retrieval medicine, advanced trauma care, advanced airway management, ventilator management, HEMS program operations.

Troubleshooting Hypoxemia After Placement of an Extraglottic Airway.

The case presented here highlights the feasibility of using an extraglottic airway device as a conduit for delivering high levels of lifesaving positive end expiratory pressure (PEEP), as well as other means of combating recalcitrant hypoxia. The case also highlights the merit of an approach to the hypoxic patient with an in-situ extraglottic airway device based not only on deciding if the device is functioning to maintain a patent airway, but also, simultaneously considering the patient's physiology. A 71 year old male suffered an out-of-hospital cardiac arrest. Part of his resuscitation included placement of a dual-balloon extraglottic airway device by EMS. He was hypoxic, but the device seemed to be providing for a patent airway without an air leak. There was also a favorable end-tidal carbon dioxide waveform. The flight team chose to the leave the device in place. PEEP was up-titrated to 17 cmH20 without issue. Sigh breaths, as well as breath holds, were also able to be delivered. The patient's hypoxia improved over the course of the patient's transport, and he ultimately did well.