When it comes to reduction of exposure to Covid, cleanliness is absolutely next to godliness, but for HEMS and SAR providers, speed is also of the essence. Crews need to be able to decontaminate an aircraft and its equipment straight away once the patient has been handed over to ensure minimum downtime. Aerosolizing disinfectants have thus become a key part of many air medical operations.

Ian Jones, Air Operations Manager for the UK’s Midlands Air Ambulance Charity (MAAC), said: “Cleaning the aircraft has been the most difficult process, but Babcock liaised with our aircraft manufacturer Airbus, to find a Covid-19-killing cleaning substance, Dismozon, that was suitable for use in aircraft and we have been using it throughout the pandemic.”

Ornge in Canada has enhanced cleaning protocols such as surface swabbing and testing, as well as introduced Nocospray for decontamination in its land ambulances. In its aircraft, it is using Aeroclave, a US-made product that recommends the use of VitalOxide, an EPA-registered hospital disinfectant that is non-toxic, and meets Boeing standards for cleaning the interiors of commercial transport aircraft.

Of course, it’s not just the aircraft that needs to be disinfected after use – every surface, every bag, every strap, needs similar treatment. US-based Virginia Commonwealth University (VCU) Health Flight Nurse and Paramedic Kevin Kissner MSN, RN, CEN, CFRN, NRP, provides support for the Virginia State Police’s helicopter medical evacuation programs. He told AirMed&Rescue: “All of our stretcher restraints and most of our equipment bags are made of a non-porous material and had been in use before we were faced with the Covid-19 pandemic. We have our bags custom made of this material to make it easier for decontamination and cleaning, easily wiped down with disinfectant wipes. This allows for faster clean-up and return to service times.” He continued: “While we used to have custom bags made (because it was hard to find the vinyl type material for easy cleaning), our newest addition of bags are by Thomas. They provide a wide variety of bags to fit many situations, as well as the option to get them in a non-porous material. They are durable, hold up to daily use, and allow us to customize our setup without difficulty.”

When the pandemic first hit and there was a global shortage of personal protective equipment, US-based air medical program Life Link III acquired Tiger Masks, which are P100 elastomeric masks equipped with internal microphones, to aid in effective communication in the aircraft as well as external speakers to aid the provider in projecting their voice to an awaiting care team in the hospital setting.

AMREF Flying Doctors used dedicated specialized medical kits for Covid patient transfers, which are packed in easy to clean plastic trunks. “With these kits,” said Medical Director Dr Joseph Lelo, “we have found it easy to separate our gear into ‘Covid and non-Covid’ kits. This has created a convenient storage and replenishment system which facilitates quick deployment especially in emergent cases.”

Kissner of the Virginia State Police noted adjustments to equipment had been made due to Covid, with the addition of new equipment and procedures to minimize exposure to the virus. These included HEPA filters, decontamination procedures, and increased PPE for aerosolizing procedures.

Improving patient isolation for a post-Covid world

Dr Joseph Lelo said that the charity has invested in four Isoarks and Isopod isolation units for Covid transports, and took the decision to invest in larger capacity oxygen cylinders.

Isolation units, however, are not the only way of giving patients the care they need without compromising on crew protection. Life Link III was the first air medical transport team in the country to utilize non-invasive ventilation helmets (Sea-Long helmet) to provide ventilation/oxygenation of patients with acute respiratory distress syndrome caused by Covid-19.

Allen Wolfe, Senior Director of Education for the program, told AirMed&Rescue: “With safety being one of Life Link III core values, our primary goal during the pandemic was to explore a means of providing the highest level of protection without sacrificing the care the patient was in need of. We learned early on in the pandemic that the patients who were intubated and placed on a ventilator had higher rates of morbidity. This device afforded us the ability to isolate the patient’s products of respiration as the helmet surrounds the patient’s entire head and seals around their neck. This helmet is connected to the mechanical ventilator via a viral/bacterial filtered circuit.” In an effort to maximize the delivery of high-flow via the Sea-Long Helmet, Life Link III’s Hamilton T1 ventilators were upgraded with the High Flow Nasal Cannula (HFNC) feature.

The potential of Point of Care Ultrasound

The use of Point of Care Ultrasound (POCUS) equipment has further enhanced the ability of critical care HEMS crews to respond to trauma situations, but any flight medic will tell you that they are also vital inside a fixed-wing air ambulance. Dr Lelo told AirMed&Rescue: “We are excited to have POCUS devices for quick diagnosis of certain conditions especially when airborne and stethoscopes are useless. The ultrasound probes are easy to use, have high definition and connect to our mobile phones or tablets.”

East Anglian Air Ambulance (EAAA) in the UK has been using a handheld ultrasound device – the Butterfly iQ – since March 2021 following a successful trial, meaning scans can be done mid-air and information quickly relayed to emergency teams on standby, speeding up treatments. Dr Jon Barratt, POCUS lead at EAAA, said: “We’ve been trialing the Butterfly iQ portable ultrasound for a number of months and the value it brings is transformative to the care we’re able to provide our patients.”

EAAA also hope to eventually use this technology to enhance the care its teams can currently offer some patients, by utilizing the large blood vessels in the groin to administer enhanced lifesaving interventions. For example, said the organization, this could have a significant impact on the treatment of cardiac arrest patients and relies on the enhanced imaging capabilities that the device can provide.

Andrew Downes, Head of Service Improvement and Clinical Quality for EAAA, commented: “The ability to share scans remotely to our team of ultrasound experts and clinicians is greatly improving the care we’re able to offer our patients by aiding continuous improvement in this area. For the first time, senior members of the team can see what our crews are seeing on the scene and quickly provide their analysis.” Another game changer about this approach, he added, is that it gives senior staff the ability to provide remote training to crews – which, in this era of ongoing social distancing and infection control, is all the more important.

Further progress in this area is being made by STARS in Canada, in association with Skytrac. Together, the two completed a medical data transfer trial onboard STARS’ Airbus 145D3. The medical data transfer capability is the first of its kind to enable air medical operators to transmit real-time patient medical data such as O2 and CO2 saturation, pulse rate, and blood pressure data directly to remote transport physicians and receiving centers.

Working in partnership, Babcock Australasia and Ambulance Victoria deliver mission-critical helicopter emergency medical services (HEMS) and search and rescue (SAR) operations across Victoria, Australia, and are working on a similar project. The team uses a patient monitor with 12-lead ECG capability that’s transmissible. Ambulance Victoria Manager Air Operations Anthony de Wit told AirMed&Rescue: “This allows for the receiving hospital to prepare the cardiac catheter laboratory to receive a patient who may be suffering from a heart attack. It also allows for the MICA Flight Paramedic to initiate treatments to manage a patient’s vital signs such as heart rate and blood pressure.”

The Butterfly scanner was also selected by AirMed, the program run by University of Utah Health. Dr Steve Bott, Assistance Medical Director, told AirMed&Rescue that they now carry the device on every single aircraft. In fact, the investment made in new equipment by AirMed in the last 12 to 24 months has been substantial, and includes:

• Hamilton ventilators for every aircraft (eight)
• Sapphire IV pumps for every aircraft
• Tablets for every aircraft
• Blood coolers and refrigerators, and temperature monitoring systems for every base/aircraft
• Belmont IV fluid warmers for every aircraft
• One neonatal isolette
• One Heartmate ECMO pump
• Three iSTAT blood gas analyzers
• Powered patient lift for fixed-wing aircraft.

Life Link III also transitioned to a new POCUS device, the Philips Lumify, which Wolfe said ‘offers a user-friendly interface, crisp imagery and provides clinicians with an immediate ability to rule out life-threatening conditions and guide treatment modalities’.

Point of care bloody analysis tools are also incredibly valuable to HEMS paramedics, said the Ambulance Victoria team, which uses the Sonosite iViz. De Wit commented: “It allows the MICA Flight Paramedic to titrate their management of the patient to blood gas analysis, especially when using the Hamilton transport ventilator.”

Investing in quality video and simulation solutions

Life Link III has had a busy last 12 months, and when speaking to AirMed&Rescue, also noted its investment in high-fidelity simulation equipment known as VIMEDIX by CAE. “This simulator provides the most realistic and advanced training possible to ensure patient safety when providing critical care transport,” said Wolfe. “It allows the clinical teams to sharpen their cognitive and psychomotor skills, so they can seamlessly integrate POCUS into their routine clinical management. This high-fidelity simulator facilitates the learning process for cardiac, lung, abdominal and OB-GYN ultrasound studies – all on one common platform.”

Kyle Madigan RN, MSN, CMTE, Director, for Dartmouth Hitchcock Advanced Response Team (DHART) told AirMed&Rescue that the program has recently upgraded its video laryngoscopes, and is now using the Glidescope Go, ‘which provides our medical team with additional options of blade selection, as well as being able to video the procedure for QA/QI processes’. Further investment has been made by DHART in transitioning to the new Hamilton ventilator.

AirMed&Rescue also reached out to the Los Angeles Sheriff’s Department – the largest Sheriff’s department in the US, operating a dedicated Aero Bureau consisting of patrol helicopters, and an Air Rescue 5 unit.

Air Rescue 5 operates three AS332L1 Super Puma helicopters where the aircrew are qualified as SWAT team members and paramedics. The unit is currently testing and evaluating some new medical equipment, as discussed by Deputy Joe Palomino of LASD: “Right now we’re testing the Airtraq endotracheal tube, which has a camera. That piece of equipment allows me to actually look at the vocal cords so I’m able to get positive affirmation that I’m intubating the trachea and not the esophagus. We’re also testing the AccuVein – that allows us to quickly visualize veins so we can establish a line. That can be particularly helpful for trauma cases and younger children. For any new equipment we evaluate how often we might use it, what’s the maintenance on it, and if it is affordable.”

Bariatric patients require specialized care

For obese patients, it’s not just specialized care that they need – the equipment the team must use to get them to the hospital is also vital. AMREF flies aircraft including Citations, Pilatus PC12 and a Eurocopter AS350, and they are under a strict weight limit of 150kg for their medical equipment onboard. For the charity’s Cessna Citation Sovereign 680, the team is procuring a Lifeport Powered Loading System which, said Dr Lelo, ‘will provide an extra safety net for our staff and patients especially in bariatric cases’.

At Ornge in Canada, all patients are transferred using the same Helimods Stryker stretcher system, so there are no concerns about if a bariatric patient should need emergency transport, as the team is prepared for it already. The Powered Aero Loader (PAL) is a zero-lift, push-button operated powered stretcher loader system for rapid loading and unloading of land ambulance stretchers into air ambulance helicopters. Bringing these loaders onboard in a few years ago, Ornge recognized that it allowed the service to offer an enhanced capability to transfer bariatric patients without the need to reconfigure its aircraft.

Madigan of DHART told AirMed&Rescue: “One of the best investments we have made in our program was the addition of the Stryker Powerload system to our ground ambulance fleet. Along with the Power-Pro XT ambulance cot with the Expandable Patient Surface (XPS) rails, we have found this system very useful for patients up to 700 pounds.”

In the tight confines of a helicopter cabin, crews can rely on various piece of equipment to ensure quality patient care, one of which is the LUCAS chest compression device. Not new perhaps, but one that Wolfe of Life Link III says continues to make a real difference to patient outcomes. The device provides consistent, high-quality, automatic chest compressions, which allows the clinicians to provide other necessary patient care while remaining securely seatbelted. The air medical program’s PC12NG aircraft, meanwhile, is fitted with an electric loader to minimize the risk of injury while loading or unloading bariatric patients.

For AirMed in Utah, Dr Bott said: “Only two of our six rotor-wing bases have aircraft that have the space and payload capacity for the really big patients. We will switch one of our smaller helicopters for another bigger one to help meet this demand in the next year. Powered stretchers are a non-starter for [our] rotor-wing operations because they’re too heavy.”

Road vehicles also require specialized equipment

Not all HEMS patients are going to make it to a hospital helipad, and the need for critical care cars and ambulances also increases the need for specialized equipment onboard to ensure seamless care can be provided to patients all the time. For this reason, said Dr Joseph Lelo, AMREF also procured a new ground ambulance stretcher system from Ferno. “This creates a redundancy that enables quick turnaround during high-demand periods. A patient can be offloaded on one stretcher and we can immediately put in the clean new one and deploy for another patient without waiting for the patient to be handed over and the stretcher cleaned.”

MAAC already operates two critical care cars, tasked predominantly to medical emergencies, in addition to its three helicopters, which attend a greater proportion of trauma-related incidents. Due to the success and additional resource this offers to saving lives across the Midlands, the charity has recently purchased a further two critical care cars, thanks to grant funding. And for bariatric patients, MAAC calls on health partner West Midlands Ambulance Service, which has specialist bariatric ambulances, so if they are required.

Ambulance Victoria noted the importance of compatibility of equipment between road ambulance and helicopter. “This is an extremely valuable initiative,” said the spokesperson. “It’s a huge patient care improvement and uncommon in other services. This initiative allows for direct transition of patients stretcher from road ambulances to helicopters, thereby improving response times. It also aids in reducing patient movement, thus reducing the need for increased pain relief and improves pre-hospital scene times thus expediting the patient arriving at hospital sooner.”

Investing in the future of critical care

The investments made by air medical programs around the world is testament to the passion the teams have for the art of critical care medicine in the air. Prehospital medicine continues to make progress, and the companies providing the products and services that allow physicians to enhance the service they offer to patients are making a real difference to patient treatment and outcomes.

Dr Steve Bott summed it up nicely when he said: “Better technology is making tertiary critical care in the air possible.”