When protocol calls for going aero-medical and the first due is un-available for whatever reasons, is next due requested? How do you judge reasonable response times of the helicopter versus taking a unit by ground? If patient is a true tramau, do you take by ground to the closest facility for stabiliztion or to the closest tramau facility?
AIR AMBULANCE SAFETY CONSIDERATION
GUIDELINES
Criteria:
A. Landing zone operations associated with use of an air ambulance.
Exclusion Criteria:
A. These guidelines provide general information related to safety when interacting with air ambulances. This general information may augment information that is provided by local air ambulance services, but since specific recommendations may differ by aircraft type or other factors it is not meant to supercede such information.
Procedure:
A. Landing Zone (LZ) Recommendations:
1. Location:
a. Global Positioning Satellite (GPS) systems may assist providing precise location of LZ.
2. Size:
a. Depends on size of aircraft, most use 100¡¯ x 100¡¯.
b. A larger LZ is recommended when higher surroundings and obstacles are present or multiple aircraft are responding.
3. Slope:
a. Must be relatively level.
4. Ground cover:
a. Dust can cause ¡°brown out¡± where dust generated by rotor wash obscures pilot¡¯s visualization.
b. Snow can cause ¡°white out¡±.
c. Both can be planned for and overcome by pilot¡ªbe prepared for lots of blowing debris.
d. Gravel¡ªrotor wash throws gravel¡ªbroken windows, paint damage, eye injuries can occur.
e. Other¡ªbe aware of anything in and around LZ such as twigs, tents, charts, linen, mattresses, rope, scene tape, garbage cans, turnout gear, rescue and medical equipment.
f. Mud¡ªaircraft can sink resulting in structural damage and difficulty taking off.
g. Brush--should not be more than 1-2 ft deep, may need to be cut or tramped down.
5. Obstacles:
a. Antennas, buildings, towers, wires, poles, hills, etc up to a mile from the LZ should be reported to the pilot. Do not assume that they see them.
b. Other obstacles in the immediate vicinity of the LZ must be identified and relayed to the aircraft by the LZ Officer--Wires, poles, signs, antennas, trees, fences, geography, ground depressions, livestock, bystanders, apparatus and other vehicles, buildings, grave markers, etc.
6. Using roadways as LZ:
a. NO vehicular traffic through LZ, including police, fire, and EMS vehicles.
b. NO pedestrian traffic.
c. PSP and local police maintain authority in decision to close roadways and thoroughfares.
B. Marking the LZ:
1. Mark 4 corners of desired landing spot with a 5th marker on side wind is coming from, so that the pilot can determine wind direction for landing
2. DO NOT POINT WHITE LIGHTS AT THE AIRCRAFT AT ANY TIME!!! (Blinds pilot, ruins night vision.)
3. Flares
a. Good at night can be seen from a great distance.
b. Limited use during the day, hard to see from the air.
c. Be aware of fire potential caused by rotor wash.
d. Be sure to collect after use.
Effective 09/01/04 192-1 of 2
Pennsylvania Department of Health Operations 192 - BLS ¨C Adult/Peds
4. Traffic cones
a. Easy to see in daylight.
b. Blown over easily unless weighted.
c. Not useful at night unless internally illuminated by very bright light.
5. Strobes are not useful.
6. Vehicles are not recommended, as they become obstacles.
7. Personnel are not recommended as markers.
8. Rotating red, yellow, or blue lights
a. Easy to see at night from miles away.
b. Pilot may ask for them to be turned off after LZ is identified depending on overall illumination
9. Miscellaneous:
a. Control bystanders to prevent their approach to aircraft and LZ.
b. Pilot always has the final say in LZ acceptance.
c. Many variables occur even if LZ has been used in the past.
C. Rotor craft safety:
1. All personnel should be outside LZ during landing and take off.
2. Never approach the aircraft unless requested or accompanied by air ambulance crewmember from the air ambulance.
3. Never open doors or operate aircraft mechanisms under routine conditions.
4. Never approach aircraft from front or back¡ªonly from the side and only when requested by a crewmember.
5. Tail rotor spins at high rate making it difficult to see and avoid, some are close to the ground (within striking distance to humans).
6. Main rotor systems vary widely¡ªsome types come within 4-5 ft of ground.
7. No running near aircraft.
8. No smoking within 100 ft (jet fuel and oxygen present).
9. No vehicles inside LZ.
10. Never approach or depart from an aircraft on a side where the ground is higher than the ground the aircraft is sitting on.
11. All loose objects must be secured before aircraft lands and departs.
12. Close all vehicle doors during landing and take off.
13. An engine company at LZ is not necessary unless required by local protocol.
14. Hot Loading:
a. Follow air ambulance crew direction carefully.
b. Wear turnout gear if available including eye, head, and ear protection.
c. Remove all baseball caps and hats and store safely.
d. Approach Aircraft only when accompanied by air ambulance crew.
e. After loading the patient, depart aircraft and LZ by the exact path used to enter.
f. Never carry anything that is higher than the level of your head (including IV bags.)
Effective 09/01/04 192-2 of 2
Pennsylvania Department of Health Operations 180¨C BLS ¨C Adult/Peds
TRAUMA PATIENT DESTINATION
STATEWIDE BLS PROTOCOL
CRITERIA:
A. All patients, in the prehospital setting, with acute traumatic injuries.
EXCLUSION CRITERIA:
A. Patients who are being transported from one acute care hospital to another.
B. Patients who do not have acute traumatic injuries, or patients with a medical problem that is more serious than any associated minor acute traumatic injuries.
C. Patients transported by air ambulance services. Air ambulance personnel will use the Statewide Air Medical Transport Trauma Patient Destination Protocol #190.
POLICY:
A. Extremely critical patients that are rapidly worsening:
1. Patients with the following conditions should be transported as rapidly as possible to the closest receiving hospital: 2
a. Patients without an adequate airway, including patients with obstructed or nearly obstructed airways and patients with inhalation injuries and signs of airway burns).
b. Patients that cannot be adequately ventilated.
c. Patients exsanguinating from uncontrollable external bleeding with rapidly worsening vital signs (for example, a patient with severe hypotension and rapid bleeding, from a neck or extremity laceration, that cannot be controlled.).
d. Other patients, as determined by a medical command physician, whose lives would be jeopardized by transportation to any but the closest receiving hospital.
2. The receiving facility should be contacted immediately to allow maximum time to prepare for the arrival of the patient.
B. All other patients with acute traumatic injuries: Use accompanying flow chart to determine patient¡¯s trauma triage category, and transport accordingly: 3
1. Category 1 trauma patient destination [These anatomic or physiologic criteria are strongly correlated with severe injury and the need for immediate care at a trauma center, when possible]:
a. Transport patient to the closest trauma center 4,5 by the method that will deliver the patient in the least amount of time if patient can arrive at the closest trauma center in ¡Ü 30 minutes. Otherwise contact medical command, if possible, for assistance in determining destination.
b. Consider air transport if either:
1) Air transport will deliver the patient to the trauma center sooner than ground transport, or
2) Patient has a GCS ¡Ü 8, and air ambulance crew will arrive at patient in less time than the time to transport to closest trauma center.
c. Communicate patient report and ETA to receiving trauma center as soon as possible, because this permits mobilization of the trauma team prior to the patient¡¯s arrival.
2. Category 2 trauma patient destination [These patients may benefit from evaluation and treatment at a trauma center, but mechanism of injury alone is not strongly related to serious patient injuries. If ground transport to a trauma center can be accomplished in ¡Ü 30 minutes, air transport is generally not necessary for these patients who do not meet anatomic or physiologic trauma triage criteria.]
a. Contact medical command if required by regional protocol. Note: EMS regions may require attempted contact with medical command for assistance with destination decisions for Category 2 trauma patients.
b. Reassess patient¡¯s condition frequently for worsening to Category 1 trauma criteria.
c. Transport patient to the closest trauma center 4,5 if patient can arrive at the closest trauma center in ¡Ü 30 minutes. Otherwise contact medical command, if possible, for assistance in determining destination.
d. Consider air transport if ground transport time is > 30 minutes.
Effective 09/01/04 180-1 of 4
Pennsylvania Department of Health Operations 180¨C BLS ¨C Adult/Peds
e. Communicate patient report and ETA to receiving trauma center as soon as possible, because some trauma centers may mobilize a trauma team for Category 2 trauma patients.
3. Category 3 trauma patients [Transportation of these patients to the closest receiving facility is generally acceptable.]
a. Transport to appropriate local receiving hospital
b. Reassess patient frequently for worsening to Category 1 or 2 criteria.
C. Air medical transport considerations:
1. When choosing transport by air, in addition to the actual transport time, which is clearly faster by air, EMS personnel should consider the amount of time required for arrival of an air ambulance, patient preparation by the air medical crew, and patient loading.
2. When air ambulance transport is indicated, EMS personnel should request the closest available air ambulance through the local PSAP. The incident command system, when in place, should be used to accomplish this request.
3. The air ambulance may bring equipment and personnel with resources that are not available on the ground ambulances. These may be useful in the following situations:
a. Patients with GCS ¡Ü 8 may benefit from advanced airway techniques that the air medical crew can perform.
b. Air medical services may transport specialized medical teams for the treatment of unusual situations (for example, severe entrapment with the possibility of field amputation).
4. Prolonged delays at scene while awaiting air medical transport should be avoided.
a. If an air ambulance is not available due to weather or other circumstances, transport the patient by ground using policy section C to determine destination.
b. If patient is not entrapped, transport to an established helipad (for example a ground helipad at the closest receiving hospital 6,7, an FAA helipad at an airport, or other predetermined landing zone) if the ETA to the helipad is less than the ETA of the air ambulance to the scene.
D. Considerations related to contact with medical command:
1. When medical command is required for a Category 1 or 2 trauma patient, contact a medical command center accessible to the EMS provider using the following order of preference:
a. The receiving trauma center if the destination is known and that center is also a medical command facility.
b. The closest trauma center with a medical command facility.
c. The closest medical command facility.
2. If the EMS crew has any question regarding the facility to which a patient is to be transported or whether the transport should be made by ground or air ambulance, the crew shall contact a medical command facility for direction.
3. If the patient will be transported by air ambulance, the air ambulance crew will determine the destination based upon the Statewide Air Medical Trauma Patient Destination Protocol.
4. Transport by ambulance to a facility other than the closest trauma center is permitted if directed by a medical command physician if the medical command physician is presented with medical circumstances that lead the medical command physician to reasonably perceive that a departure from the prior provisions in this protocol is in the patient¡¯s best interest. This may occur in special situations including the following:
a. Specialty care is required that is not available at the closest trauma center (e.g. pediatric trauma center resources or burn center resources).
b. The closest trauma center is on ¡°diversion¡± based upon information from that center.
c. The patient or other person with legal authority to act for the patient refuses transport to the closest trauma center.
Notes:
1. Patients in cardiac arrest who have penetrating trauma or are in third trimester (>24 weeks) of pregnancy should be taken to the closest trauma center if time to arrival at the closest trauma center is 15 minutes or less. Otherwise, patient should be transported to the closest hospital.
2. Transport should generally not be delayed while awaiting the arrival of ALS service or an air ambulance unless the ALS service or air ambulance has a confirmed ETA to the scene that is less than the ETA to the closest hospital.
Effective 09/01/04 180-2 of 4
Pennsylvania Department of Health Operations 180¨C BLS ¨C Adult/Peds
3. Although these categories may be useful in identifying patients who should be transported to a trauma center during a mass casualty incident, patient transport prioritization should follow the system identified in the regional/ local mass casualty incident plan.
4. ¡°Trauma Center¡± refers to a Regional Resource Trauma Center (Level 1) or a Regional Trauma Center (Level 2) that is currently accredited in this commonwealth and similarly qualified trauma centers in adjacent states. The most current Department lists of these resources should be used for reference. This definition of trauma center applies throughout this protocol.
5. Pediatric patient considerations: Patients that are 14 years of age or younger may be transported to the closest pediatric trauma center (which includes an adult trauma center with additional qualifications in pediatric trauma) if the patient¡¯s condition is not extremely critical (see policy section B.1. above) and the difference between transport to the closest trauma center and transport to the pediatric trauma center is no more than 10 minutes.
6. If the patient is not entrapped, EMS personnel should generally not wait on scene for an air ambulance if the ETA of the air ambulance is longer than the ground transport time to the closest hospital¡¯s helipad. Established helipads are generally safer than scene landing zones, and the resources of the adjacent hospital are available if the air ambulance is delayed or has to abort the flight. When using a helipad that can be accessed without entering a hospital, the patient¡¯s transport should not be delayed by stopping for evaluation within the hospital. If there is a significant delay in the arrival of the air ambulance, the patient should be taken to the hospital¡¯s ED for stabilization. Contact with medical command may be used if doubt exists about whether the patient should be evaluated in the hospital¡¯s ED.
7. This does not apply to hospital rooftop helipads that require access through the hospital. If a patient must be taken through a hospital to access their helipad, EMTALA requirements may cause a delay while the patient stops for an evaluation in the ED. EMS personnel should avoid accessing these receiving facilities for the use of their helipad unless the patient meets the criteria of extremely critical patients who are worsening rapidly as defined in Policy section B.1. above.
Performance Parameters:
A. Review all cases where patient meets criteria for Category 1 or 2 Trauma for appropriate destination and appropriate use of air transport.
B. Review on-scene time of all patients meeting Category 1 or Category 2 criteria. Consider possible benchmark of <10 minute on-scene time at in at least 90% of non-entrapped cases. Review all cases where on-scene time is > 10 minutes for appropriateness of care and documentation of reason for prolonged on-scene time.
Effective 09/01/04 180-3 of 4
Hope this will help you understand a little bit more.