RE: Opinions/Advice (follow-up, long post/rant)

[Ken Lawson-Williams <Macgyver@FlightMedicMail.com>]

First, Yes Alyssa, telling the MD to blow goats would have been most satisfying. Using his head as a cribbing block also a novel/attractive idea. We also did end up using a construcion heater (Herman-Nelson) to blow warm air onto patient while exposed during loading/unloading and time it took to secure to the stretcher at recieveing airport. 

Second, let me say thanks for all the support and input. It is always useful to see how others would respond within their programs - often it leads to ideas that can be imported into ones own program. That being said, it is always necessary first to shed the blinders of "we have always done it that way" and "that's the only way to do it" unless the situation exactly mirrors ones own. Which almost never happens. Resources available and local medical protocols see to that. Not necessarily the way it should be, but reality nevertheless. 

OUTCOME: Arrived safely, still have pucker factor cramps. Dilation on arrival (via portable ultrasound) was 10 cm. Test performed as patient was being unstrapped and transferred supine to OR bed. Baby moved via handling/flight vibration/ground transfer vibration into frank breech position. Successful c-section delivery 18 min after arrival. Baby fine. Mother complicated closure due to weight / skin integrity issues.
Time required to set up/implement plan: 62 minutes. Total increase in time over a "normal" trip due to pecularities of this case = 55 minutes. Increase in time required to load/unload from aircraft/ambulance (and slower ground speeds): 13 minutes. Total time at risk (transport phase): 70 minutes. 

In this case the options I assessed were: 
(1) Stay and have a non-surgically trained GP assisted by equally untrained staff in an unequipped facility perform a risky proceedure likely to result in maternal death, probable child survival.
(2) Fly in traditional position and have in-flight medical incident resulting likely in death of both
(3) Fly  in nontraditional position (to prevent/postpone furthur dilation and membrance pressure increase and labour development) and deliver in facility capable of handling complications BUT with risk of death to both if aircraft related or ambulance related incident occurred.
The probability of an aircraft/ambulance crash was in my opinion much less than that of worsening labour. So - develop a system to accomplish option 3 that was as safe as it could be possibly made within the limited time/facilities available.

ISSUES RAISED: (here's where the post gets rant-y and long) 

MISSION ACCEPTANCE: Get ready for this, one of the worst things about this program, THERE IS NO EFFECTIVE ACCOUNTABILITY OR MEDICAL OVERSITE FOR MISSION ACCEPTANCE. I agree 100% that this needs to be resolved/improved. All of us would love to have consistant medical direction that is involved/proactive and knowledgable of our work. What saves us is a CFN who is a RN/Medic with 24 years flying experience in Northern Canada and the best clinical mentor you could hope for. However, the contracting hospital still can, and does, override her judgement and recommendations leaving her onlu withdrawl of service ultimatums to resolve critical issues. Our protocols get constantly updated/modified, but GP's ofetn override to their comfort level. Documentation gets tedious but has saved our buts on numerous occasions when things have gone south as we predicted and they ignored - then tried to deny their orders.

Any nurse in an outpost nursing station, first aider at a mining camp etc can call for a Medevac. No acceptance guidelines in place. GP in ER at recieving rarely will say no as afraid of consequences if not transported and since never knows requesting person's clinical skills/reliability so has to go face value with whatever they say (often incomplete assessment or talked up to get a flight). No retrospective review by hospital (who pay the bills) or government (who fund the hospital). As a result since 1995 flights have gone from 30-45 per month to 80-90 per month, and available aircraft from 3 to 2 (less time on ground therefore contractor was able to reduce mileage rate. Unfortunately this means it is a onstant juggle to get to all flight requests and keep A/C maintained.) / available staff constant at 3 per shift (6x24 / 4days off). 

Flight medical crew in our program are not authorised to cancel calls. CFN can, but rarely does as private company and wants to keep contract/job. NO MEDICAL CONTROL INVOLVEMENT in this type of decision. Attitude is "this is the North / we don't have the resources for every eventuality / people die (ie: the shit happens argument). Legal environment nowhere near as bad as USA. Very few natives will sue - more fatalistic I guess plus WAY less lawyers willing to work on contingency (also most law firms do most of their buisness with government). Captain can cancel a flight for safety or weather reasons but rarely do as also a contractor and captains who cancel too often are shuffled sideways back to the cargo fleet - ending their chances of continuing into executive or scheduled airline positions.
 
Agree re: A/C no place to deliver. Program has NEVER done so x 10 yrs with 27% of flights high risk OBS/Neonate related. Heaven protect (from the CFN) the team that screws up their assessment and is forced to. Protocols call for primips greater than 6 cm / multips greater than 4 to stay and deliver at sending. Will assess, initiate tocolytics, stay untill stable enough to not deliver for duration of flight time plus IFR reserve (45 min) plus 45 min for recieving admission/assessment process. Tocolytics include MgSO4, Indocid, Dexamethasone. Delivery at sending = flight team + public health RN / industrial EMT at sending facility, OHIO transport incubator (old but well insulated - 2 degrees celcius loss outside per 30 min at -40 if protected from wind during transport to A/C by RCMP/mine safety open pickup truck), delivery room = assessment table in average 12'x12' room in ATCO construction trailer type facility, telephone contact to OB/GYN at recieving 66% time available. Flight crew wait at airport until no time left for them to return to sending + IFR reserve and postflight duties, then will leave us / return and exchange crews (occasionally possible for 2nd aircraft to come and relieve but not always). Only happened once as delivery is usually within 1-2 hours. 

If tocolysis innefective, term, or distressed will stay and deliver. Personally delivered 18 since '91 under these conditions including twinsx2 sets (1 at 22 weeks = both DOA), 1 breech and 1 dystocia. Complications (knock on wood) low with 2 PPH (carry oxytocin, as well as albumin and plasma, rarely have O- available, usually can get ergot and hemabate from hospital prior to launch), 4 mec and one stillbirth. Also carry Exosurf, used x 1 but 7 deliveries were under 34 weeks. Prenatal care up here spotty at best with huge FAS / FAE and smoking problems. NICU team WILL NOT COME TO COLLECT NEWBORN as their pilots refuse to fly into unpaved bush strips. So we then transport all back to sending and they (THEN!!) call NICU PRN (another 3-5 hour wait prearrival with newborn in community hospital nursury, then 3-4 hours untill babe admitted back at their NICU). We could be at the tertiary NICU from 1 to 3 hours before their team even arrives at sending but are not allowed to do so by sending pediatrician (No neonatologist. Rationalle = may/do need intubation, thus NICU trip. Never mind we have often already resuscitated!!). 

GROUND OPTIONS: None (see earlier posts). Most places we fly into have no road access (not even 4x4) at all. Hence we function as air ambulance -vs- high speed trauma evac / inyterfacility transport like most helicopter programs. Some communities will have 4x4 passable ice road for several months. However (for example) one community of 250 that is 35 minutes by air, takes 7 hours by 4x4 on ice roads / bush cut-lines (road only open 6 weeks a year) and speed limited to 20 mph or will break through the ice. Also NO ALS ground of any description. BLS only in 4 of 30+ comunities, and ambulances in only another 2 (manned by fire dept vol. first aiders

SINGLE CREW: Agree in very general terms that this is not the ideal. However, 40% of our flights are routine BLS transports for tests, minor injuries etc. another 13% are pediatric bronchiolitis/otitis/RSV etc "clinic visit" type trips. So basically no different that a single Paramedic in the back of a 2-person ground ambulance crew. So what is the problem here? Protocols dictate that on cardiac, unstable, serious trauma, maternity and ANY call the primary flight medical crew member feels they would like a second set of hands on (or where the patient MIGHT possibly deteriorate to that state) they take a second. True - this system relies on your ability to elicit information from the sending person that accurately reflects the patients condition and prognosis for the period from time of call to recieveing admission (from 3 to 10 hours). However we often know these community health RN's etc from repeated visits, and thus who is reliable/whose assessments suck/who panics easily/who thinks they can handle more than they can etc. (So why don'tthe GP's let us decide the priority, and weather medevac or scheduled flight? Got me....). 

You can get caught. I have. only once in 600 flights so far (touch wood again) where what I got was not what I expected (RSI + vent req'd so had to strip mine of their advanced first aider to assist - and caused the mine to be shut down until he returned) but with this level of responsibilty and authority we tend to play it safe. In this case, weight / space restrictions precluded taking 3 flight medical crew (including the MD). My personal choice would have been one of my team, but the MD over-rode. As suspected by some, I think he thought that if necessary he would be required to do an emergent c-section in-flight. Not on my watch.

As to quitting. Believe me on day 3 of 6 after 60 of 72 hours on missions (most of which were not medicaly not immediately necessary) I certianly think of it. Especially when saying goodnight to the second line flight crew for the second time while eating whatever I have left in my flight bag. But I don't know of many programs that have the variety of responses, patient types, isolated locations that actually need/benefit from your work/medical autonomy (double edged sword if you don't know your stuff) and weird-shit calls. It's wilderness/rural ground work using an airplane but with critical care equipment and off-line extremely liberal protocols. Too much fun (now at least, when I have managed to get a good nights sleep...).

SAFETY: Security of stretcher in King-Air worked very well (wish I had digital camera - as per earlier thread - would help to address some of the safety issues rightly raised. A picture is worth a thousand words.) I don't know if good for 25G crash-decelleration but flight crew all experienced cargo loadmaster types prior to obtaining pilot positions and couldn't move basket at all once they had done their magic. Toes were about 10" below ceiling as basket stretcher braced by seat and seat back at foot end and "X" strapped to floor tracks. Less than 1/2" lateral and no vertical motion possible (up or down). Head of basket strapped to tracks immediately aft of wing spar (all other seats on port side removed and left at sending airport along with incubator - couldn't take as would obstruct emergency exit). Decelleration bracing by wing spar and 2 additional "x" straps from basket cross member near shoulders aft to floor tracks (just in front of rear seat holding up the foot) = 6 point security. 

Loading was accomplished with 4 firefighters (total=3 people in A/C and 5 on ground during evolution - made MD assist with EMS cot control) Prior to loading rear of aircraft braced with A/C maintenance jack from another avaition company located on airport to prevent nose wheel lifting off ground. Cargo door allowed patient to be oaded with angle maintained throughout (all except aft facing port side seats removed first then 1 seat replaced after head secured). Improvised sheet "X" accross pt. shoulders to take pt weight during decellerations worked well. (Cargo door can be seen in one of the revolving pictures on the home page at www.airtindi.com)

Biggest problem during transort was ground portions where basket was secured rigidly to cot frame in reverse orientation with pt head strapped rigidly to foot against the oxygen bottle carrier (stryker, pad removed first) and head of cot elevated to maximum position. Gas shock couldn't take the load of the basket resting on it's top member so I braced an "E" cylinder against front cross member/safety catch bar  and placed the cot's head crossbrace member on the O2 regulator between the twist handle of the regulator and the tank valve (regulator forward and under no load) so cot brace trapped between them = no motion. "X" cargo straps x4 to basket at shoulder area (decelleration) and foot to maintain position of highly elevated foot of basket with additional looped staps x 2 to maintain position of O2 cylinder. Cot at lowest position until time to load. 

Feet cleared top edge of door by 2", 6 man cot lift (didn't attempt to use roll-on system) with 2 inside ambulance to steady foot and guide into position. Additional 2 straps from basket feet sideways to EMT-catcher net roof mount (same track connectors as A/C) on right side and through hole in cabinetry for LP power cord (between LP mounting brackey and inverter mounted behind access panel) to minimize lateral motion during corners etc. Slow/smooth transport with lights and Fire Dept escort at intersections (needed them at hospital to assist in unloading).

KLW

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