Air Ambulance - Special Treatments
1) Head and Neck;
a) Balloons: All balloons e.g. nasal balloons for posterior nasal bleed shall be filled with water whenever possible.
b) Trapped air: Aircraft pressure may need to be adjusted for patient comfort due to the expansion of trapped air in sinuses, dental cavities, or middle ear blockage. Patients with intracranial or intracerebral air will need to be flown at or near a sea level equivalent pressure. Patients prone to middle ear block will be offered chewing gum and/or afrin nasal spray if clinically appropriate.
c) Eye injuries: Cabin pressure may need to be adjusted for patients with eye injuries. In addition, these patients and patients with recent eye surgeries shall have their heads elevated and immobilized during flight. Supplemental oxygen will be used for all patients with recent eye injury or eye surgery. (due to the high oxygen requirements of the retina).
d) Neurology insults: All patients with head injuries, brain injuries, or cranial surgery shall be loaded with their feet to the rear of the aircraft. The patients head will be elevated to 30 degrees. Oxygen saturation will be maintained at or above 95%. Foley catheters will be inserted. Patients with a Glasgow Coma Scale (GCS) score of 9 or less shall be intubated unless their baseline GCS is normally 9 or less, or unless they have a valid current DNR requesting no intubation. NG tubes will be inserted unless the patient has a cribform plate or basilar skull fracture.
e) Eye humidification: Comatose patients shall be given artificial tears every ho8ur during a flight unless eyelids are taped closed. Patients and passengers with contact lenses shall be offered moisturizing eye drops at frequent intervals. (e.g. Visine).
f) Seizures: All patients with a history of seizures, or have a high potential for seizures shall be evaluated for anticonvulsant medication and/or sedation.
g) Trauma patients: If the patient complains of c-spine, examine x-ray. If not x-ray not available, apply neck brace prior to transport.
h) Wired jaws: An antiemetic shall be given prior to transport. Wire cutters shall be available in the event of emesis.
2) Cardiovascular;
a) Trapped air: Patients with decompression sickness or those who are at risk of decompression sickness shall be flown at a sea level equivalent altitude for pressurization purpose.
b) Hydration: Fluids po shall be encouraged (clinical condition permitting) or IV’s administered or adjusted to compensate for low humidity environment. Patients shall receive frequent mouth care with lemon glycerin swabs or fluids.
c) Recent MI or unstable angina: those patients shall be flown in accordance with Intensive Air’s unstable angina/recent MI protocol.
d) Shocks: All patients in shock of any kind shall have an NG tube inserted.
e) CHF: All patients in CHF shall have oxygen saturation at or above 95%. They shall be placed with their feet to the rear of the aircraft, and transported in a sitting or semi-fowler’s position.More…
3) Pulmonary;
a) Trapped air: Patients with a pneumothorax shall have this air vented via closed chest tube or needle decompression. If venting is not possible, cabin altitude will be adjusted to accommodate this.
b) Air filled devices: Airway cuffs shall be filled with water to prevent excessive tracheal pressure.
c) Suctioning: Patients with artificial airways shall be suctioned prior to flight, then at each refueling stop. Frequent suctioning may be required depending on the patient’s clinical condition.
d) Pulmonary secretions: Thick and difficult pulmonary secretion may be worsened by the low humidity. Mucous plugs may form. Patients with this problem will be offered humidified air via mask or Guifesen preparations to act as expectorant/mucolytic.
e) Oxygen: Oxygen will be available on all flights. All flights should prepare for at least 2 lpm. Any patient with a known disease or condition that lessens tissue oxygenation, (e.g. CHF, anemia, COPD, narcotics) or whose condition might be aggravated by hypoxia shall be placed on oxygen during flight and oxygen saturation at or above 90% at all times. (Exceptions to this are addressed elsewhere in this protocol). Patients already on 100% oxygen prior to flight will need to be flown at lower altitudes to maintain adequate oxygenation.
f) Special precautions for chronically hypoxic COPD patients: Patients with severe COPD whose oxygen saturations normally run less than 90% should be given only enough oxygen to maintain their “normal” oxygen saturation. Attempting to go higher will only lead to further carbon dioxide retention and possible respiratory arrest or cardiac arrest.
g) Severely obese patients: To reduce the risk of barobariatrauma, the patient will be placed on 100% oxygen for 15 minutes prior to transport. Oxygen saturation will then be maintained at or above 95% throughout the flight with supplemental oxygen.
h) Appropriate oxygen supplies: For patients known to require oxygen, the Medical Coordinator will calculate the amount of oxygen needed to meet the patient’s needs from “pick-up” to “delivery”. Due to potential unforeseen delays in patient transport, a minimum of 150% of the calculated need will be loaded along with the patient.
4) Gastrointestinal;
a) Air filled devices: All balloons shall be filled with water, when possible. If not possible, the pressure must be monitored closely. (e.g. esophageal blake more tubes for bleeding varices.
b) Trapped air: NG tubes, orogastric tubes, and colostomy bags shall be vented during flight, not clamped.
c) Patients with non-vented intestinal or peritoneal air: e.g. bowel obstruction or recent surgery may need cabin pressure adjusted to the avoid complications of air expansion.
d) Air sickness: Patients who are prone to or who develop air sickness shall be offered an antiemetic. This can be done by mouth, injection (IM or IV), suppository (e.g. phenergan) or patch such as trans-derm Scop.
5) Genito-urinary;
a) Air filled devices: Balloons such as foley catheters shall be filled with water when possible.
b) Voiding: Patients shall be encouraged to void prior to flight as well as during fueling stops. For patients who cannot void easily, foley catheters will be considered on all flights which are expected to be 6 hours or longer.
6) Skin;
a) Patient shall be turned and repositioned at least every two hours whenever possible. For flights over 4 hours, the stretcher should be padded to reduce tissue breakdown.
Quality Assurance
American Air Ambulance has an active Quality Assurance Program. At the completion of each flight, the transport team’s flight notes are sent to the corporate office where the Medical Director and Medical Coordinator carefully review them. Any areas of concern are noted and discussed with the flight crew, as well as provided to the flight teams. In addition, an evaluation card is sent to the family after the flight, requesting them to evaluate our service and the care provided to the patient. This comprehensive Quality Assurance Program enables us to continually evaluate ourselves, and consequently maintain our highest level of service and care to our patients.
