Flightmed archive for August-2002
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Flightmed archive for August-2002

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RT question, BiPap-v-CPAP (+scenario)

Can the Bird Avian III be set up with carefull adjustment of PEEP, flow
rate and upper/lower pressure limits/alarms in the CPAP setting to mimic BiPap? Or to do a better job at replacing BiPap during flight than free-flow via tightly applied non-rebreathing mask? 

Also, other than  the mask itself, are there any other attachments required for CPAP than the standard vent circuit and peep valve?

I am looking for info/guidance on the following recent flight/interfacility transfer issue - and how would your service handle it...  (EMTLA / COBRA not in effect here) Feel free to reply off-line if preferred.

SITUATION: Pt. COPD, in ER x 6 hrs, on BiPap x 4, transferred out (3 hr ground transfers plus FW flight, would require 13 hours by road) to ICU as sending facilities ICU closed. Recieving Internist wanted pt to arrive unintubated (weaning issues). Sending GP complied. CFN said OK but MD from sending must accompany/retain care of pt. as was against our protocol/common sense to remove from BiPap and fly 3 hrs on a non-rebreather. Sending facility would not load BiPap machine for trip (7-8 hours out and back). MD sent was GP with 1 year of additional ER training and no aeromedical training who does about 5 ETT/yr and 2 or 3 flights a year. Busy organising RSI meds of his own to bring when arrived at ER. Unfamiliar with staff training/experience/equipment. 
Never has RSI or ETT in BE-200.

1) Ignore CFN after "on the spot" assessment of situation, assume care and RSI per our protocols and fly on ventilator? (last similar case required ETT within 35 min of takeoff when patient crumped) (puts job in jeopardy but protects license)

2) Suck it up and do as told - fly on NRB with fingers crossed and let MD deal with whatever happens? (the "told you so" response with lots of documentation)

3) Fly as ordered but advise MD that ETT (if req'd) was team's responsibility and use own meds/protocols etc? (again with lots of documentation)

4) Refuse trip after consulting with CFN/sending/recieving MD (our medical director unavailable)? (puts contract in jeopardy)

Please give rationalle (if you have the time).

OUTCOME: Pt made it to ICU OK. Took some explaining to pilot (basically 
a demand), to get a step climb of cabin altitude from 800'ASL (sending) 
to 2200'ASL (recieving) spread out over the duration of the flight (135 
min so basically 100' climb every 10 minutes). Confusion over climb rate of aircraft -vs- of cabin altitude. Had passed message on so could be flight planned and climb points predicted (basic on cabin pressure differential) while patient being packaged etc. but had never done it before - was not sure of proceedure - didn't think it necessary.

Required declaration of MEDEVAC status (=LIFEGUARD) and direct routing with several different aircraft altitudes en-route (including appopriate ATC clearances etc), with subsequent cabin bleed valve manipulation (down again) as aircraft climbed to second cruise altitude and bleed valve could be re-opened (thus maintaining cabin climb undisturbed by aircraft altitude). The First Officer got to spend a lot of time with cabin pressure/bleed valve and flight planning/filing in-flight! (good review :) for him).

We spent most of the time watching pt. like a hawk, charting and varying the oxygen rate to maintain SPO2 at 92% (so as to maintain drive per accompanying MD) as the cabin pressure changed and the patient compensated etc. An interesting trip - but am still not sure was best compromise solution....

Fly Safe. 

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