Treating the injury, not the crisis - Stuart Elms, Clinical Director, EHAAT

“It is highly unlikely that we would ever fly a patient having an isolated mental health crisis as we do not routinely get tasked to this group of patients,” said Stuart Elms, Clinical Director, Essex & Herts Air Ambulance (EHAAT). EHAAT is a UK-based charity that provides Helicopter Emergency Medical Services (HEMS) for the critically ill and/or injured. According to Elms, one response that is not considered, however, is a chemical or a mechanical restraint on a patient in crisis. “If a patient suffering a crisis has become combative through injury, such as a traumatic brain injury, a clinical assessment determines whether sedation or pre-hospital anaesthetic is used; we treat the injury rather than the crisis,” said Elms.

At times, however, a temporary manual restraint may be needed to gain IV access to allow patient care to take place, added Elms. “This type of response would be minimal,” he said. “We apply ‘deescalation’ techniques, such as continuously talking to the patient. All team members are trained to identify the ‘red flags’, such as positional asphyxia and excited delirium (ExDS).”

Positional [postural] asphyxia is a form of mechanical asphyxia that occurs when a person is immobilised in a position which impairs adequate pulmonary ventilation and thus, results in a respiratory failure. Based on findings published in the 2016 Front Physiol Journal, research by the National Center for Biotechnology Information (NCBI), part of the National Institutes of Health (NIH), explained the characteristic symptoms of ExDS, including bizarre and aggressive behaviour, shouting, paranoia, panic, violence toward others, unexpected physical strength, and hyperthermia. Throughout the US and Canada, these cases are most frequently associated with cocaine, methamphetamine, and designer cathinone abuse.*

“In all cases, we work within the guidelines of the National Institute for Health and Care Excellence (NICE) and the Mental Health Act Code of Practice to ensure the patient receives the best possible care for the condition,” said Elms. NICE is an executive function of the Department of Health in the UK that provides guidance and training for public healthcare professionals. The Mental Health Act of 1983 Code of Practice was revised in 2015 to reflect guidance for patients, their families, and carers regarding their rights.

Front Physiol. 2016; 7: 435.Published online 2016 Oct 13. doi:  10.3389/fphys.2016.00435 Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum, Deborah C. Mash, [the article has been cited by other articles in the PMC].

Type and severity of psychosis

Dr David Sinclair, consultant in Anesthesiology, Critical Care and Emergency Response Medicine, and Medical Supervisor, European Air Ambulance

Personal views, as well as professional advice that European Air Ambulance (EAA), Dr David A. Sinclair would recommend to a fellow physician in his role as the medical supervisor, stated that the method of response in treating a combative patient mid-flight depends on the psychosis. “It definitely depends on the type and severity of the psychosis,” said Dr Sinclair. For example, a compliant delusional patient might need neither sedation nor restraint, he explained. “On the other hand, an agitated schizophrenic patient might need both in extreme,” said Sinclair.

The decision to restrain or sedate the patient is made upon safety concerns knowing the cabin is a severely sensitive environment where a short outbreak by the patient can endanger the lives of the entire crew, he explained.

Minor psychotic patients with no concomitant diseases are sometimes managed on commercial aircraft with an EAA physician accompanying, he explained. “Severe psychotic patients or patients with concomitant diseases are transported by air ambulance,” added Sinclair.

To include or not to include a family member during air transport of the patient can turn out as a ‘mixed blessing’, said Dr Sinclair. “The crucial factor is in the intellectual differentiation or emotional distance of the family member/friend,” he said. “They must be fully aware, that in extreme, they might witness disturbing scenes [and be prepared to deal with them]. Otherwise, the medical team must take care of two hysterical patients at the same time.”

Positive experiences with close friends or relatives who escorted the patient do exist, however, said Sinclair. “The more distant relationship might be the better choice than close family members,” he said. “If the patient is a minor, a parent should accompany.”

Research: In-flight Pharmacological Management of Acute Mental Health Disturbance

Dr James Garwood, Specialist Registrar in Anaesthetics and Pre-hospital Emergency Medicine

Dr James Garwood, in conjunction with two additional researchers, published in a recent issue of Air Medical Journal their research paper, In-flight Pharmacological Management of Acute Mental Health Disturbance [AMHD]. When presenting these findings at the International Aeromedical Transport – Concepts in Airborne Patient Management conference in London in April 2018, the research caused ‘quite a bit of controversy amongst some of the other doctors who were present (in terms of physical restraint)’, said Garwood.

The research objective studied 110 patients [air] transferred many hundreds of kilometers with AMHD for specialist mental health services in Western Australia during a four-month review of 130 flights, according to Royal Flying Doctor Service Western Operations, Australia (WA) records. Garwood’s experience in aeromedical transfer of patients with AMHD comes from his work with the Royal Flying Doctor Service (RFDS), WA in terms of moving patients who were ‘acutely psychotic. The RFDS ‘best practice’ followed the transfer of mental health patients policy, which was written in conjunction with WA government, WA psychiatrists, and the RFDS-WA’, according to Garwood.

AMHD causes

“The causes of AMHD can be ‘organic’ or ‘non-organic’,” explained Garwood. “Organic causes are generally a true psychiatric disorder from chemical imbalance within the brain, and are a longer-term condition, whereas the non-organic causes are, for example, from drug abuse (crystal meth is a classic), or acute infection, such as meningitis.”

The key is to treat the cause of the psychosis, which may be with pharmacological methods (antipsychotics such as olanzapine) or to treat the non-organic cause by treating the infection and reversing possible physiological causes, he explained.

“The vast distances in WA necessitates the need to use air transportation to be treated by a tertiary (inpatient) psychiatric unit,” Garwood explained. “The balance of risk vs harm generally falls on the fact that it would either be a drive of over 30 hours, or a three-hour flight to transfer. It would be overall less of a risk to move the patient rapidly by a critical care team than by road by a team of police officers with minimal medical cover.”

In his current role as a senior flight doctor with Capital Air Ambulance in the UK, Dr Garwood’s workload is generally more of an Intensive Care Unit [ICU] repatriation service. “As part of our contracted work, we could be tasked with moving a patient from an offshore/island location to the UK, which would either involve a 30-minute flight (dedicated air ambulance or commercial aircraft) or a ferry crossing of some hours.”

Transporting AMHD patient protocols

Garwood explained that when moving patients with AMHD, it is important to ensure:

• Patients are moved for the correct reasons, such as a clinical need, as opposed to ‘commercial or organisational’ pressures
• We do no harm with either the patient’s sedation or manual restraint, and
• The patient causes no harm to the flight crew or put the security of the aircraft in jeopardy.

“The aim should be for a balanced approach with a calm and relaxed patient that, although they may have restraints fitted, they are not physically restricted from movement or adjusting their position on the stretcher,” said Garwood.

According to the research conclusion, the rate of in-flight incidents including violence remained low. Additionally, the research stated the transfers of patients with AMHD ‘are challenging; and that high quality preflight assessments and in-flight care are required to minimise the associated risks’.

Research Study: In-flight pharmacological management of acute mental health disturbance, Air Medical Journal Volume 37, Issue 2, March-April 2018, Pages 115-119;

Researchers: Brian Wilkinson MBBS, FRCA; James Garwood, BMBS, FRCA, MAcadMEd, DipRTM.RCS(Ed), PGCClinEd;Stephen Langford, FAFPHM, FRACGP, FACAsM, AFRACMA, DipRACOG, DipAvMed, GAICD1

Fitness-to-fly and direct dialogue

Graham Williamson, CEO, LIFESUPPORT Air Medical Services, Inc.

Canadian-based LIFESUPPORT Air Medical Services, Inc. is a global provider of international patient transportation, by fixed-wing air ambulance, commercial airline medical escort, and inter-continental commercial airline stretcher, in which ‘each and every mission is assessed and handled on a case-by-case basis’, said CEO Graham Williamson.

Direct dialogue, conversation, and involving the patient in decision making is key, he said.

“Decision making is multi-layered, which begins with a fitness-to-fly declaration from the sending facility, followed by a review from our medical team, and our chief medical officer, in collaboration with the assistance company,” explained Williamson. “The medical team must carefully consider the case, meet with the patient and treating team before the mission, before the transport is fully confirmed. Medical protocols are available to assist the patient in becoming comfortable and relaxed for the journey.”

Medical teams are equipped with physical and chemical restraints, but this measure is only used in an emergency. “The use of restraints is an extreme measure,” said Williamson. “If it comes to that, really, the patient was not fit to fly in the first place. We would never plan to transport a restrained psychiatric patient in advance.”

Building a relationship, creating an understanding and collaborative relationship is fundamental; it is more powerful than any drug, explained Williamson. “In most cases, the patient wants to return home,” said Williamson. “Having a familiar family member or friend along for the journey is very valuable. If flying commercially, the family member or friend should also be seated in business class with the medical escort and patient.”

A well-trained medical escort who is very familiar with the nuances of international air travel, security protocols, and air medical flight, working collaboratively with the patient, family and treating medical team, will have the best chance of success, he said.