Ever done an RSI in a helicopter? Here’s a recent simulation experience!

Recently at the base, we’ve been discussing the concept of improving our ergonomics and making our workspace (e.g. the helicopter) as functional as possible. We are continually looking to optimize our equipment to best serve our patients.  Any procedure in-flight will be considerably more difficult than if performed in a well controlled environment like the hospital so in-situ training within the helicopter is essential.

Today, Karl (one of our advanced paramedics) and I did some in-situ simulation of an RSI within the helicopter. We ran through a scenario with an unpredicted deterioration of a patient in flight that required an RSI. A review of the literature provides little guidance on the emergency airway management of patients while in-flight so approaches to such situations currently must be derived from simulation and retrospective reviews within your own program.

We discussed a few key concepts that should be considered as we move forward in pre-hospital airway management and overall care for acutely ill patients:

1. Patient positioning: ample evidence that patient’s should probably have some head elevation if possible during intubation (If you don’t believe me…check out this must read paper). This IS possible within the BK and it actually provided Karl with the best view when it was up near 40-45 degrees! Check out the following pics which demonstrates feasibility within the BK.

Patient is fully supine. Experts advocate "ear to sternal angle" but in our traditional position of supine you'll note that the ear is NOT at the sternal angle!

Patient is fully supine. Experts advocate “ear to sternal angle” but in our traditional position of supine you’ll note that the ear is NOT at the sternal angle!

And now, for a clear demonstration of “ear to sternal angle”. A position we should strive to do either to avert intubation or in preparation of an advanced airway.

A picture perfect view of the cords!

A picture perfect view of the cords! Patient at 40 degrees, and still able to intubate with a great view…even with the helmet on. Let’s integrate this!

2. Pack position: we decided that the airway/BMV pack would be removed from the Thomas pack and given to the intubating clinician immediately upon patient deterioration. This allowed the paramedic to have all necessary equipment for excellent airway management. The physician could then focus on drug administration and clinical decision making. We opened the Thomas pack fully beside the physician and placed the drug pack on the patient’s legs.

Note the drug pack on the patient's legs and the Thomas pack spread out to the right of the physician. This worked best in our setting.

Note the drug pack on the patient’s legs and the Thomas pack spread out to the right of the physician. This worked best in our setting.

Here’s what DIDN’T work.

This set up was very cumbersome if the drug pack is lying on a partially open Thomas pack. Another issue was the Thomas pack was still upright...and not lying flat.

This set up was very cumbersome if the drug pack is lying on a partially open Thomas pack. Another issue was the Thomas pack was still upright…and not lying flat. Also harder since we had to turn each time to get drugs rather than in front.

3. Apneic oxygenation: this is a bit trickier and something we’ll have to look at more closely to see what would be feasible since it will require 2 O2 sources. It was definitely challenging to get it set up when time constrained. (another must read paper on the value of apneic oxygenation).

Huge thanks to Karl for running through the sim case and providing value feedback on the ergonomics of the situation…what worked and what didn’t! We will all learn from this.

2 thoughts on “Ever done an RSI in a helicopter? Here’s a recent simulation experience!

  1. Reblogged this on Sim and Choppers and commented:

    Nothing is quite as anxiety provoking as having to emergently manage a patient’s airway while in the back of helicopter…communication is different, access to the patient is different, the environment is loud and we have little experience intubating there! This is why we do in-situ simulation…a great session with one of our advanced paramedics.

  2. Nice work guys!

    In this sort of situation having the ergonomics of it sorted out in your head PRIOR to the proverbial hitting the fan is crucial, and you guys have just given us a foundation to work from.

    This highlights the importance of simulation training in the actual physical environment you work in (or something very close to it). Russell Clarke flagged an article to us today which focuses on this, and terms it a “natural synthetic environment” – “The goal is to synthetically recreate the natural environment in which the learner will eventually practice, with as much attention to
    detail as possible.”

    I think simulation training for in-flight emergencies in the back of the number 2 machine (when not in use) with helmets, life jackets, comms etc is a fantastic “natural synthetic environment”.

    Pubmed reference is here

    Full text pdf is here (secure area limited to ADHB staff only – ADHB maintains an online subscription to this journal through the Philson Library at the University of Auckland School of Medicine)

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