| The use of helicopters-to transport patients is becoming the standard of care for many critically ill and injured persons requiring transportation to a specialized center. However, there is no well-established body of clinical literature that delineates the best criteria for dispatching a helicopter to an emergency scene.
Operational situations in which helicopter use should be considered:
1. Mechanism of injury
· Motor vehicle accidents have occurred at 20 mph or
more and the occupants are not wearing seatbelts;
· Vehicle rollover with unbelted passengers;
· The passenger area of the motor vehicle is compressed
to 18 inches;
· Vehicle striking pedestrian at >10 miles per hr;
· Falls from >15 feet;
· Motorcycle victim ejected at >20 miles per hr:
· Multiple victims.
2. Difficult access situations:
· Wilderness rescue;
· Ambulance egress or access impeded at the scene by
road conditions; weather or traffic:
3. Time/distance factors:
· Transportation time to the trauma/medical center
greater than fifteen (15) minutes by ground ambulance.
· Transport time to local hospital by ground greater than
transport time to trauma center by helicopter;
· Patient extrication time >20 minutes, or
· Utilization of local ground ambulance leaves local
community without ground ambulance coverage.
Clinical Guidelines
1. General
· Trauma victims need to be delivered as soon as possible
to a regional trauma center.
· Stable patients who are accessible to ground vehicles
probably are best transported by ground.
2. Specific
Patients with critical injuries resulting in unstable vital signs require the fastest most direct route of transport to a regional trauma center in a vehicle staffed with a team capable of offering critical care enroute. Often this is the case in the following situations:
· TraumaScore<12;< />
· Glasgow Coma Scale score <10;< />
· Penetrating trauma to the abdomen, pelvis, chest,
neck, or head;
· Spinal cord of spinal column injury; or any injury
producing paralysis of any extremity if any lateralizing
signs;
· Partial of total amputation of an extremity (excluding
digits);
· Two of more long bone fractures or a major pelvic
fracture;
· Crushing injuries to the abdomen, chest or head;
· Major burns of the body surface area, or burns involving
the face, hands, feet or perineum, or burns with
significant respiratory involvement or major electrical or
chemical burns;
· Patients involved in a serious traumatic event who are
less than 12 or more than 55 years of age;
· Patients with near drowning injuries, with or without
existing hypo-thermia; and/or
· Adult patients with any of the following vital sign
Abnormalities:
1) systolic blood pressure <90mmHg.
2) respiratory rate <10 or />35 per min;
3) heart rate <60 or />120 per min; or
4) unresponsive to verbal stimuli.
Discussion
With the increased use of helicopters to fly patients to regional trauma facilities, there is a pressing need for clearly defined criteria to decide which patients shall receive air transport. Physicians, pre-hospital technicians, patients, third-party payers and government agencies are searching for established standards to indicate the appropriateness of individual transport decisions. This paper provides a consensus of a group of physicians involved in the day-to-day operations of emergency medical services in the United States.
The growth of emergency medical helicopter transport services over the past two decades has stimulated a variety of controversies. This position paper seeks to clarify only one of these controversies: the utilization of helicopters for scene responses. There is no discussion of many other debated issues regarding air medical transport of patients such as: utilization of helicopters for inter-hospital transport; utilization of fixed-wing aircraft: weather condition and the use of Visual Flight Rules (VFR) versus Instrument Flight Rules (IFR); appropriate numbers and types of medical personnel to staff die aircraft; financial liability of these services or the ability of patients to pay the transport fees, and the manufacture and model of fixed-wing or rotary-wing aircraft best suited for the mission.
Transportation of the critically ill or injured patients is a difficult task for ambulance services. The problem can be compounded by long transport times, long distances to facilities. Or transport of patients from areas that are inaccessible by road. The decision to request helicopter transport for the patient from the scene to or between hospitals may be difficult as ambulance crews may have concerns about being "second-guessed" when air medical transport is requested. While improved levels of patient care is the desired endpoint, other factors also are considered when air medical transport is requested, including the logistical aspects of the situation and scene. These aspects are unique to every scene response. Each of the guidelines above addresses a separate clinical or operational point by which the mode of transport needs to be decided. While each of them represents a singular sufficient criterion, when multiple criteria exist in a single setting, the need for helicopter transport from the scene becomes even more pressing.
Because it is in the patient's best interest to use the helicopter when the patient situation or clinical condition justifies it, the guidelines listed must be distributed widely to all parties involved with air medical transport. It is important that physicians, hospital administrators, and emergency medical services directors be familiar with these criteria so that they may develop air medical transport resources locally and create local guidelines for access to existing resources.
Pre-hospital technicians, public safety officials (including law enforcement, fire, and highway patrol officers), and agencies with public-use lands should use these guidelines to decide when to contact their local medical control physician and discuss the need for a helicopter scene response in specific situations. These guidelines should be shared with public and private insurance companies responsible for paying for these services so that the agency supplying the services may be reimbursed appropriately. Without such reimbursement, the agencies are unlikely to continue to be able to offer such services.
The guidelines delineated above for appropriate utilization of emergency helicopters for scene response are made available for wide dissemination and recognition. Individuals, groups, and agencies are encouraged to engage in further discussion of these criteria in order that all parties involved may reach a global consensus about the appropriate criteria for helicopter scene responses.
References (Jan-Mar 1992)
National Association of Emergency Medical Services Physicians and American College of Surgeons.
Air Medical Services Committee of the National Association for Emergency Medical Services Physicians (NAEMSP) has developed a set of guidelines for scene responses by helicopters. These guidelines have been adopted as the official position of NAEMS. And are presented for use by the emergency medical services community.
A set of guidelines, whether brief or exhaustive, cannot foresee clinical or operational instances in which the helicopter medical crew may be useful at an emergency scene. In many respects. the local emergency clinician will be the best arbiter of this question in as much as the local clinician will have the most intimate understanding of regional resources. In presenting these guidelines, NAEMSP emphasizes the fundamental importance of closely integrating resources so that ground and air services mesh smoothly and efficiently in the best interest of the patient.
1 . Burney RE: Efficiency, cost and safety of hospital-based emergency aeromedical services (editorW). Ann Emerg Med 1987;16: 227-2-99.
2. Champion HR: Helicopter triage in Jacobs LW and Benett BR (eds.) Emergency Care Quarterly (Helicopter EMS) 1986;2:13-21.
3. Fischer RR Flynn TC, Miller PW, et al: Urban helicopter response to the scene of injury. J Trauma 984;24:949-950
4. Knopp R, Yanagi A. Kallsen G, et al: Mechanism of injury and anatomic injury as criteria for prehospital trauma Lriage. Ann Emerg Med 1988;17:895-902.
5. Rhodes M. Perline R, Aronson J, et al: Field triage for on-scene helicopter transport. J Trauma 1986;26.963-969.
6. Urdaneta LF, Sandberg MK, Cram AE: Evaluation of air transport service as a component of a rural EMS system. Amer Surg 1984;50:183-188.
|
