What is our company Aerocare, The Flying Ambulance all about:

Introduction

Aerocare is an air ambulance service dedicated to providing fast and professional medical rescue to the Free State as well as the Northern Cape, Eastern Cape and Lesotho regions.
Specializing in the medical evacuation of critically ill and injured patients. We “bring the ICU” to the patient. Our highly trained medical crew, consisting of doctors, paramedics and ICU sisters, ensure that medical transfer occurs within a safe and highly skilled environment.


Our Equipment

1. Monitoring and Defibrillation
Phillip’s Heart Start – Monitor defibrillator which can monitor heart rate, ECG, saturation, respiratory rate and end tidal CO2, it also has a 12-lead ECG facility, the ECG can be faxed from the aircraft or rural area to the home base as it is done. Defibrillation capabilities include pacing and an AED as well as the usual defibrillation. This is a biphasic machine.

2. Ventilation
We carry an Oxylog Drager 2000 which is capable of SIMV, SIPPV, IPPV and CPAP. This is a rugged, sturdy ventilator which is easy to operate.

3. Suction
We have a portable Laerdal suction unit that can also be taken with in the ambulance.

4. Immobilization Equipment
We carry a scoop, a vacuum mattress, head blocks, cervical collars (adult and paed), a Kenrick extrication device and a Thomas splint for immobilization of femur fractures.

5. Ivacs and Syringe Drivers
We carry 2 IVACs and one syringe driver routinely when flying; all infusions are run through the IVACs because of the effects of pressurization.

6. Other Equipment, Disposables and Drugs
Please see attached drug check lists. We also carry a full advanced life support bag with BVMs, ET-tubes, drips, chest drain insertion kit, urinary catheters and other necessary consumables. We are fully self-contained and have enough equipment to respond to any emergency as the need arises.

7. Neonatal Equipment
We have an ATOM transport incubator as well as a Neopuff for emergency ventilation of a prem or neonate.


Medical Staff

According to Civil Aviation law, all flights must have at least 2 medical personnel on board and preferably 2 per patient. The lowest qualification must be intermediate life support. As a general rule we fly with a medical doctor and an ICU sister or at times a doctor and a paramedic. We have 2 full time ICU qualified sisters who do weekly equipment checks and perform most of the flights. We use a relatively large pool of part time doctors so as to best meet the patient’s needs. (see below)

When a flight is activated, the medical co-ordinator contacts the referring doctor and based on the patient’s condition then contacts an appropriate flight doctor to do the flight. During the flight, close contact is kept with the medical co-ordinator as well as the receiving specialist as need be. As a general rule, doctors are given a basic management suggestion based on the history from the referring doctor, however, this may alter depending on the flight doctor’s findings, and therefore it is imperative to have highly trained doctors.


Minimum Medical Requirements for Flying Doctors

Although there are currently no laws in South Africa at present governing the training requirements, we adhere to the following unless there are exceptional circumstances –

1. Trauma
Includes all trauma patients, including burns and head injuries.
• Dedicated trauma unit experience, A&E casualty experience, ICU/anaesthetic experience or general surgical training.
• ATLS qualified
• Children less than 3 years of age will be transported by doctors with the above qualifications and time in either paediatrics or paediatric surgery or experience in anaesthetics.

2. Acute Care and Medical Emergencies
Includes disease entities such as DKA, sepsis, overdoses, cardiac failure and respiratory failure as well as related conditions.
• Experience in internal medicine, A&E casualty experience, anaesthesiology or intensive care experience.
• If the patient is intubated and ventilated or is on inotropes, then experience in a multi-disciplinary intensive care unit or experience in anaesthesiology is essential.

3. Cardiac Emergencies
Any patient with an acute coronary syndrome or an unstable arrhythmia.
• Experience in internal medicine, A&E casualty experience or intensive care experience.
• If the patient is intubated and ventilated or is on inotropes, experience in a multi-disciplinary intensive care unit, extensive anaesthesiology experience, or experience in a cardiology unit is essential.
• ACLS qualified

4. Paediatric Medical Emergencies
This includes all patients below the age of eight years.
• Experience in paediatrics.
• APLS/PALS qualified
• If the child is less than one month of age then either dedicated neonatology intensive care training or extensive anaesthetics experience is essential.
• In stable children, over the age of three, extensive anaesthesiology, internal medicine, or A&E experience, will, at the discretion of the flight directors, suffice for minimum clinical experience.


5. Obstetrical Emergencies
Includes all pregnant and peripartum patients.
• Experience in obstetrics, A&E casualty or intensive care.
• If the patient is intubated and ventilated or is on inotropes, then experience in a multi-disciplinary intensive care unit or anaesthetics experience is essential.

All flight personnel undergo continuing evaluation as to their appropriateness for flight transfers.
We encourage all our crew to do an aviation medicine course, but this is not a requirement.


ICU – trained Sisters

Because most of our flights are inter-hospital transfers, having an ICU-trained sister is a valuable addition. We have two full time sisters who work one week on, one week off, thus there is always someone available immediately for flight. Should we perform a primary response, we do this with a paramedic and a doctor.


Types of Patients transferred

Aeromedical Transports in South Africa are of two types:-

i) Primary Response
In this setting, patients are picked up from the accident site or from a nearby runway. These patients are usually severely injured and the decision to fly is based on time and distance to definitive care. Primary Responses are usually undertaken by helicopters or small fixed wing aircraft

ii) Inter-Hospital Transfer
In this situation, sick patients are transferred from a hospital with limited facilities to a hospital in which definitive treatment can be undertaken. (e.g. cardiac patients, sick neonates etc) Aeromedical transfer is often undertaken because of distance and also because of level of care required by the patient. (see later)

Primary Responses are usually performed by helicopters, but may also be performed by small fixed wings depending on location and proximity to a runway.


There are a number of standard criteria which are normally applied for primary responses:-

AEROCARE PRIMARY RESPONSE CALL OUT CRITERIA

ANATOMIC FACTORS
• Severe penetrating trauma to the head, neck or torso with shock
• Major amputation above the ankle or wrist
• Amputation with possibility of re-implantation
• Partial spinal cord lesions
• Where cervical spine injury is suspected
• Threatened limb
• Children with burns > 20% body surface area
• Adults with burns > 30% body surface area
• Inhalational injury
• Significant trauma child under age of 12 years
• Severe head injury
• Shock despite initial fluid resuscitation
• Revised trauma score of 10 or less

MECHANISM OF INJURY
• High energy dissipation – rapid deceleration
• Passenger space of vehicle invaded by 30cm or more
• Ejection from the vehicle
• Death of another passenger
• Deformity of contact point
• Multiple injured passengers
• Falls from 5 meters or more or from a height twice the patients length

MEDICAL CONDITIONS
• CVA within thrombolytic window period
• MI within thrombolytic window period
• Acute subarachnoid haemorrhage
• Acute respiratory distress
• Declining LOC
• Exposure to life threatening toxins or chemicals

Any of the above along with a situational factor is a medically justifiable indication for a primary response.

SITUATIONAL FACTORS
• Distance greater than 150 kilometres by road from base of operation
• Increased ground transport time
• Inaccessible location by road
• Need for specialised equipment and or personnel at disaster scene
Interhospital Transfers

1. Decision to Fly vs. Drive
Doctors often think that it will be much quicker to load the patient into an ambulance and let them drive for 5 hours rather than wait for 2 hours for aeromedical transfer – this logic is extremely flawed for a number of reasons-

2. Capabilities of Staff Doing Transfer
In South Africa, especially in the rural areas, most of the ambulance staff have basic qualifications – meaning that although they can administer oxygen, or even put up a drip (if they have intermediate qualifications), they do not have the necessary training or protocols to be able to deal with serious complications during transfer.
In an Aeromedical transfer, a doctor and a fully qualified paramedic or ICU/trauma sister do the flight – in this situation, competent treatment of complications will occur.

3. Referring Doctor Responsibilities
From a medico-legal point of view, the referring doctor is responsible for the patient’s management until the patient reaches definitive care – therefore if complications occur en route, the doctor could be held liable

4. Pre – Trip Stabilization
Staff doing Aeromedical transfers are trained to stabilize the patient prior to transfer. Sometimes referring hospitals may not have the necessary expertise to cope with really sick patients – e.g. decision to intubate a neonate etc. – in these situations, obviously it is in the patient’s best interests to be flown.

5. Medical Condition
Patient’s with unstable spinal injuries should be flown as injury deterioration is less likely.

v) Patient Comfort
Usually an aircraft trip is much more comfortable than a long bumpy road transfer, this may be an important consideration for patient’s condition. (e.g. unstable angina)


Typical Patient Transfer Protocol

1. The incoming call from the referring doctor or medical institution is received by the Safety Officer who then establishes the patient’s details and records them.

2. The Safety Officer informs the medical co-ordinator of the flight. The medical co-ordinator liases with the referring doctor and establishes full medical details, fitness to fly and if any additional equipment will be needed for the flight.

3. The Safety Officer at this stage begins with the administrative aspect of the flight and starts preparing quotes and the other financial issues surrounding the flight.

4. The medical co-ordinator liases with the Safety Officer or the Flight Nurse to ensure that any additional equipment, drugs, fluids etc are made available and are loaded on board the aircraft.

5. The medical co-ordinator determines the best-suited medical crew for the flight and either contacts them directly or may delegate the task. In most instances the “list of suitably qualified doctors” is used to mobilise medical aircrew.

6. The medical co-ordinator informs the Medical Institution responsible for Authorization of the flight and liases with them to ensure that Aerocare may dispatch its crew as a matter of urgency.

7. The Safety Officer faxes the quote and patient’s details to the medical aid / medical assistance company.

8. Upon receiving the authorization from the Medical Institution the correct gear and crew are loaded and dispatched.





Addendum – Drug Check list

DRUG BAG 1

AGENT VOLUME QTY
Adenosine 6mg 2ml 5
Adrenaline 1:1000 1ml 16
Aminophyilline 250mg 10ml 1
Atropine 1mg 1ml 6
Atrovent 0.5mg 2ml 4
Berotec 1,25g 2ml 4
Brevi-block Vial 1
Calcium chloride 10% 10ml 2
Calcium gluconate 10% 10ml 2
Cordorone X 150mg 3ml 3
Decazone/Decadron 4mg 4
Dextrose 50% 50ml 2
Dispirin 100mg Tabs 6
Dobutamine 250mg 2
Dopamine 40mg/ml 1
Epanutin 250mg 5ml 4
Lasix 20mg 2ml 6
Lignocaine 2% 5ml 5
Magnesium 1g 10ml 4
Mannitol 12,5g 2
Metachlopramide 10mg 2ml 3
Naloxone 0.4mg 1ml 5
Nitrolingual spray 0.4mg Spray 1
Phenergan 25mg 2
Saline 0.9% 10ml 2
Sodium bicarb 8.5% 50ml 2
Solu-Cortef 100mg 2ml 5
Stemetil 12,5mg 2
Tridil 25mg 3
Water for Injection 10ml 2
DRUG BAG 2

Actrapid 100u/ml 1
Anexate1mg 5ml 1
Chloral Hydrate 200mg 1
Diazepam 10mg 2ml 5
Dormicum 15mg 3ml 5
Esmeron 50mg 2
Etomidate 20mg 10ml 1
Ketamine 10mg/ml 20ml 1
Morphine 15mg 1ml 6
Pavulon 4mg 2ml 4
Phenylephrine 1ml 10
Rivotril 1mg 3
Scoline 100mg 2ml 3
Syntocinon 5 units 1ml 2