State of Alaska Aeromedical Physician Training Course

1. State of Alaska Aeromedical Physician Training Course Welcome to the

2. Course Objectives • Understanding of air physiology • Describe patient management in the aeromedical setting • Recognize & anticipate problems common in the aeromedical setting • Dispatching considerations • Sending and receiving considerations

3. History of Aeromedical Transports International USA Alaska

4. The first AlaskanAeromedical Transport Training Course 1980 • 120 hours of classroom training • Focused on aircraft environment • Three part exam Practical Written Oral

5. Federal Aviation Regulations They govern all civil aviation operations: FAR Part 91 (general operating flight rules) FAR Part 135 (air taxi / commercial) Violation may result in removal of certification

6. Effect of Altitude on Barometric Pressure 523 mm Hg 10, 000 feet 760 mm Hg Sea Level Earth

7. Boyles Law The volume of a gas will varies inversely with pressure, given the temperature stays the same. Aeromedical Considerations Air splints Air mattress, mast suit, etc. Air in IV tubing drip chambers Endotracheal tube cuffs?

8. Conditions in which barotrauma may be dangerous: Pneumothorax, Mediastinal, pericardial air URI with sinusitis, otitis media, mastoiditis Penetrating eye injury Diaphragmatic hernia Small bowel obstruction Recent Surgery Gas-filled abscess or cyst, Gas gangrene Following scuba diving

9. Dalton’s Law The total pressure of a gas mixture is the sum of the individual partial pressures of all the gases in a mixture. Aeromedical Considerations Pa02 decreases

10. Another Look at Dalton’s Law 10, 000 ft. 560 mm Hg 21% Partial Pressure of oxygen = 118 21% of 560 = 118 Sea Level 760 mm Hg 21% Partial Pressure of oxygen = 160 21% of 760 = 160

11. Charles’ Law The volume of a gas will vary directly with the absolute temperature, given the mass and pressure stay the same. Aeromedical Considerations Gas filled medical equipment increase size when warmed

12. Henry’s Law The amount of gas dissolved in a solution is directly proportional to the pressure of the gas over the solution. Aeromedical Considerations Scuba Divers - Must fly sea level

13. Other Gas Laws Other Gas Laws Graham’s Law - rate of diffusion Guy Lussac’s Law - pressure increase Poiseulle’s Law - volume & pressure gradient

14. Altitude affects theA-a GRADIENT Definition The difference in partial pressure of oxygen in the alveolar gas spaces and the pressure in the systemic arterial blood. A-a Gradient = [(Barometric Pressure - 47) times FIO2] - (PaCO2 /0.8) - PaO2

15. Pulm Physiology A-a Gradient What is the Aeromedical significance? 10,000 feet 560 mmHg - 47 = 513 (times the % of O2) 21% = 108 minus CO2 / Resp quotient 50 mm Hg = PaO2 58 (Predicted) Sea level 760 mmHg - 47 = 713 (times the % of O2) 21% = 150 minus CO2 / Resp quotient 50 mm Hg = PaO2 100 (Predicted)

16. Four types of Hypoxia Hypoxic hypoxia Anemic hypoxia Stagnant hypoxia Histoxic hypoxia

17. Causes ofHystoxic Hypoxia Drugs Prescriptive & recreational Alcohol one ounce = 2000 feet Cigarettes Three consecutive = 8000 feet

18. REVIEW -CELLULAR RESPIRATION Cell Mitochondria Protein, Fat, or Glucose (C6 H12 O2) Electron Transport Chain ATP 2 Pyruvate Acid Kreb Cycle 1/2 O2 + 2 Hydrogen + two electrons = Makes Water CO2 ATP CO2 O2 function: discard electron waste after ATP synthesis CO2: this is the cell waste product.

19. ELECTRON TRANSPORT CHAINDrugs, alcohol, & Smoking affect the Cytochrome Located in the Cell Mitochondria Fe.S FMN Fe.S Cytochromes Q Cyt b Fe.S Cyt c1 Cyt c Cyt a Cyt a3 Cytochrome, is a protein with a heme group. 1/2 O2

20. Factors affecting hypoxia: Altitude Rate of Ascent Physical Fitness Physical Activities Drug & Medications Individual Variations Alcohol Smoking

21. Plane Characteristics There are basic physical features similar to all planes. Basic principles of flight similar in all planes: center of gravity, lift, drag, & propulsion. There are several physical characteristics that individualize planes

22. Characteristics That Vary Among Planes Pressurized? Door dimensions Passenger capability--including flight crew Range Cabin length and height Cruise speed Electrical requirements--is it available? Runway consideration--length & surface type Payload Built in medical unit

23. Disadvantages of Pressurized Aircraft Potential for rapid decompression (Typically commercial airlines fly at 30,000 to 36,000 feet. Cabin pressure typically 5,000 to 8,000). More money : Plane and fuel Requires a longer runway Usually requires a paved runway

24. Disadvantages of Unpressurized Aircraft Air pressure fluctuates in: Body cavities Air filled tubes (i.e. Mast pants) ET Tubes? Increase patient discomfort Altered effectiveness of medical equipment

25. Typical AK Medevac Aircraft Cessna 185, 206 or 207 DeHavilland Beaver DeHavilland Otter Grumman Goose Piper Cub Piper Chieftan (Navajo) Cessna Conquest Boeing 737

26. Factors that Affect the Decision to Transport • Primary Principle--Do no further harm • Know indications for transfer • Transfer agreements • Transfer protocols • Stabilize patient • Transfer with skilled personnel and adequate adjunctive equipment

27. Overview of the Process of initiating a Medevac 1) Planning 2) Inventory of resources & equipment 3) Medical control 4) Decision to transfer 5) Factors affecting transport 6) Communication -- Dispatch / Hospital 7) Communication -- Pilot

28. Assess patient Escorts available Escorts level Required equipment Types of Aircraft Landing conditions Number of patients Condition of patients Notification Receiving community Aircarrier Family members Pre-Transport Records Clinic or ambulance Insurance info Family contact number Planning Steps

29. Clinic / Medevac Personnel Prepare, Practice, Educate A Successful Medevac startsbefore the patient gets ill. Medical Control Establish protocols, Educate Dispatch / Pilot Know what to anticipate

30. Pilot Weather Concerns Icing Turbulence Wind direction & intensity for take-off Weather at landing community Extra fuel needed due to strong winds The Pilot has the final word on weather.

31. Inventory Your Community Resources Airfields Air carriers Types of aircraft Escort qualifications Medical equipment available

32. Rescue vs Medevac

33. State of Alaska:Resources Available for Rescue Operations • Alaska State Troopers • U.S. Coast Guard • MAST • Alaska Air National Guard • Local Army Guard

34. Decision to Transfer Based on Matching: PATIENT Medevac Aircraft Escort Training level 1) ALS or BLS 2) Critical Care 3) Specialty

35. Transport with Caution Diving Gas Gangrene Pneumothorax Hypoxia Cardiac Wired Jaw Anemia Recent Abdominal Surgery

36. Rural Physician Medical Decision to Transfer Decision is made based on Weather Plane availability Staff availability and skill level Type of patient (pediatric, OB) Remember: The rural physician is taking care of the patient with out the current technological luxuries. Like CT scans, etc

37. Rural Physician Medical Decision to Transfer Conflicts arise when the “city” doctor request you fix the problem. Not understanding the diagnostic, staffing, and equipment limitations of the rural area. Education of referring physician may be necessary to avoid conflict.

38. Rural Physician Medical Decision to Transfer At times the patient stops at another community due to weather restrictions. This new health care person may alter your initial plan of care. Communication is the key to preventing a disaster.

39. Rural Physician Medical Decision to Transfer How long would you keep a patient in a remote area with out A surgeon Advanced lab capabilities CT scan or Ultrasound Knowing you only have two flights a week.

40. Rural Physician Medical Decision to Transfer Limitations in staff and supplies may force medical triage decisions. Triage Salvageable vs the non-salvageable. The sickest salvageable patient to town.

41. Rural Physician Medical Decision to Transfer Realize some people choose to stay in the rural area AMA. However, they may “change their mind”. Now, you have a sick person and may not have the supplies to take care of them. Example: Pre-eclampsia at a doorstep delivery.

42. Dispatch / Hospital Dispatch Never pressure the pilot into a flight. Inform pilot if patient weight excessive or sea-level cabin needed Never, never, never, tell the pilot the patient will die unless he flys Hospital Know names of contact people Ask for patient follow-up

43. Aircraft Orientation: Prior to a flighthave the pilot discuss the following: ELT (Not to be confused with a BLT) Survival Gear Fire Extinguisher Flotation Devices Emergency Exit Operation Oxygen Storage Equipment / Patient Tie Downs Radio

44. Essential Communication with the Pilot Discuss Air-ground radio communications Flight maneuvers (i.e. high G-force during take-off) Altitude restrictions (prior to taking on fuel) Cabin temperature considerations Weight of the patient (esp. if excessive) If electrical power available

45. Aeromedical Concerns Gas expands Hypoxia Stresses of flight Psychological status of patient & escort Equipment Available Functioning Secured

46. Aeromedical Considerations of Eye and facial Injuries Head (free air?) Chest Respiratory Abdominal Anemia / Sickle cell

47. Aeromedical Considerations of Hypothermia and frostbite Psychiatric emergencies Maternal Pediatric Burns Amputations

48. Effects of Altitude on PaO2 may be Particularly Hazardous for: Shock Severe respiratory distress (ARDS, COPD) Decompensated cardiac disease (CHF, MI) Severe anemia (especially SS) Glaucoma, eye injury, recent eye surgery Cyanotic congenital heart disease Epilepsy CNS injury requiring 02

49. Things that will injureor kill the patient: • Illness • Trauma • Too much care • Too little care

50. Matching the Escort to Patient Skill level of: EMT I EMT II EMT III Paramedic Nurse Critical Care Air-ambulance Match escort to worst pt case scenario