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.
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.
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.
Here’s what DIDN’T work.
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.
ARHT is purchasing an AgustaWestland AW169, due for delivery in 2015. This provides an opportunity to to create a purpose-built interior that will best serve the helicopters mission profiles, and a considerable amount of planning is going into this.
This paper, published in Air Medical Journal 2012, details how specific cabin elements were designed and constructed for a German EC145 (the successor to the BK117 that the ARHT currently operates). Key to the design was a sliding module containing essential medical and monitoring equipment – the module can slide a considerable distance out the rear doors of the helicopter to aid the process of loading/unloading ventilated patients with lots of monitoring equipment in situ.
Full-text pdf of this article is available 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)