General

For most air transport, commercial flights are used. Only a small number are carried out with the use of an air ambulance – in Europe it is approximately 10%. In a few countries, e.g. Norway and the USA, getting approval for the transportation of a patient on a stretcher on a commercial flight is difficult.

When ordering an air ambulance, it is important to use an experienced air ambulance company that also has an accreditation from either EURAMI (European Aero-Medical Institute, www.eurami.org) or CAMTS (Commission on Accreditation of Medical Transport Systems, www.camts.com). This is to make sure that transportation can be carried out in a professional manner and that all the aeroplanes have the necessary organisation and equipment. 

Most larger assistance organisations have specific departments handling the planning and execution of transportation by air ambulance. From now on, this will be referred to as the air ambulance section.

Reasons for using an air ambulance

There are a lot of different reasons for using an air ambulance. These reasons can be divided into “Medically reasoned air ambulance”, where the transport is justified solely on the patient’s medical condition, and “Logistically reasoned air ambulance”, where an air ambulance is chosen for non-medical reasons.

Medically reasoned air ambulance:

- The patient needs to be transferred quickly to get more advanced medical treatment.

- The patient’s condition is so serious that he or she cannot be accepted on a commercial flight.

- If the patient’s condition requires more observation and treatment during the flight than can be

  accepted on a commercial flight.

- Where, based on evaluation of the patient’s condition, there are an unacceptable number of

  stopovers/changes of aircraft.

- If the patient’s condition requires transportation at sea-level cabin pressure.

- If the patient, because of adiposity, cannot be accepted on a stretcher on a commercial flight.

- When time is crucial, for example, in the transportation of donor organs for transplantation.

- Specialist transports, for example, incubator transportation.

Logistically reasoned air ambulance:

- If there is no commercial flight connection from the destination in question.

- If the commercial airline nationally does not transport patients on stretchers.

- When it takes too long before the transport will be able to be carried out by a commercial flight.

- Due to economic reasons where, for example, the transportation of several patients by the same

  ambulance flight  (co-transport) is cheaper than individual transportation by commercial flight.

- If the patient desires an ambulance flight and is willing to pay for it.

There are many different types of patients who are transported by air ambulance, from the sitting, slightly-ill patient to the critically ill, intensive care patient, who is sedated and kept on a ventilator.

The air ambulance

These are aircraft that are either permanently equipped for patient transport or can quickly be converted to an air ambulance, having all the necessary equipment.

Helicopter

The great advantage of a helicopter is the flexibility and the possibility to land near the patient (e.g. the site of accident, hospital, etc.) and to transport the patient directly to hospital. Take-off and landing can be carried out with less acceleration and deceleration than that of fixed-wing aircrafts. Helicopters normally cruise at low altitudes, with the cabin pressure being equal to the pressure on the ground.

The disadvantages of a helicopter are more noise and vibrations compared to fixed-wing planes. The helicopter also has its limitations regarding speed and dis-tance. Transport by helicopter is usually inexpedient when travelling distances of more than 400-500km.

Smaller helicopters having less range are used for primary evacuation, transporting patients straight from the site of the accident to a hospital.

Larger helicopters that are able to fly for up to 5 hours are used for transporting the injured from, for example, oil rigs or ships.

Propeller aircraft

Domestic and regional two-engine turboprop aircrafts with pressurised cabins are used to a great extent (regionally, e.g. within Europe).

Jets

Although small jets are also utilised domestically or regionally, they are primarily used on medium-distance flights, such as Cross-Europe, to North Africa, and to the Canary Islands. They have room for 1-3 stretchers.

Larger jets are used for intercontinental transportation and typically have room for 2-4 stretchers.

Larger airplanes

A few air ambulance companies have large jets arranged with a larger number of stretchers. They are able to transport up to four intensive care patients plus a large number of seated patients. These planes are often used during the height of peak seasons, transporting a large number of recumbent and seated patients from, e.g. the Canary Islands or The European Alp Region.

In the case of major disasters involving the Nordic countries, there are standing agreements with the provision of military transport planes and passenger planes that can quickly be converted and arranged with a large number of stretchers, including some for intensive care.

PTC

Patient Transport Compartment is a fully equipped 6m2 transport cabin with the same intensive care equipment as an air ambulance. The PCT is only offered by a single airline company (Lufthansa) on their long distance flight leaving from and returning to Frankfurt.   

The arrangement of air ambulances

Accessibility

These planes are permanently organised as flying ambulances and they often have slide arrangements, which facilitate the loading of stretchers. Some of the air ambulances have special ramps on which stretchers can be slid in and out of the aircraft. A few planes have particularly large doors (cargo door), which may be of great advantage when loading obese patients.

Room for the stretcher

There must be sufficient room for the stretcher, especially near the patient’s head, making it possible to provide medical care to the patient (intubation included).

The intensive care stretcher

Typically, the intensive care stretcher is equipped with an undercarriage and a rack for other medical gear. 

The undercarriage

The undercarriage contains oxygen cylinders with outlets and connectors, a suction pump, air com-pressor, and an electric outlet providing 12V DC and (110) 220V AC.

The stretcher

It should be possible to elevate the head-end and the foot-end separately. The stretcher comes with belts, including shoulder straps.

Rack for the ventilator and the monitoring equipment.

All this equipment is either fixed directly to the stretcher, the undercarriage, or the aircraft’s interior.

The standard stretcher

The stretcher used for the stable patient has simpler components and can be with or without oxygen and electric outlet.

The stretcher for the obese patient

Both the standard stretcher and the intensive care stretcher can carry patients weighing up to approximately 120 kg. Special stretchers are available for patients above this weight.  Different providers have different policies and equipment for the transportation of obese patients.

Medical equipment

A lot of air ambulance companies fly permanently with a complete intensive care setup, equipment, and medicaments, regardless of which type of patient is being transported. This is to ensure flexibility and to be able to further deal with unexpected emergency situations. The equipment is equivalent to what is found in an emergency department. It also needs to be configured in a way that makes it possible to use for ground-transfers in “bed-to-bed” transports (which will be described in detail later).

Complete intensive care setup:

Monitor: Usually a lightweight monitor with the following functions is used:

- ECG

- Non-invasive and invasive BP

- CVP

- SpO2

- Temperature

- Capnometer 

Therapeutic units:

- Defibrillator

- External pacemaker

Ventilator: It should be able to handle advanced functions such as CPAP mask, support and controlled modes.

The primary ventilator should be an oxygen-saving type (turbine-driven). A backup ventilator of a more basic type should be available. Furthermore, there should be equipment for manual ventilation on board (bag-valve).

Intubation equipment: Tracheal tubes, laryngoscope, Magill’s forceps, cuff-pressure monitor, etc. and equipment for the management of difficult airways. 

Suction: Two separate suction pumps (electric and manual). A closed suction system for intensive-care patients is desirable.

Infusion and injection devices: A selection of infusion fluids in soft plastic bags plus pressure infusers. Equipment for establishing peripheral intravenous accesses, including peripheral venous, central venous, and arterial catheters. Equipment for intraosseous infusion should be available, 2-4 infusion pumps, depending on the patient’s condition.

Feeding tubes: Nasogastric tube, duodenal tube, etc.   

Urinary catheterisation equipment: Equipment for inserting a urinary catheter, urine bags, and suspension device.

Chest tubes: Equipment for inserting a chest tube, tubes with one-way valves, etc.

Nurse equipment: Washcloths, wash-basin, diapers, disposable gloves, waste bags, feeding cup, straws, etc.

Miscellaneous equipment: Stethoscope, BP apparatus, thermometer, etc.

Blood gas analysis: On long intensive-care transports, it is necessary to analyse the patient’s blood gases on a regular basis and in such cases an analysing device is brought on board.

Medicine: On board the air ambulance, there should be a comprehensive selection of medicine for treating a variety of diseases in relation to the airways and respiration, the cardiovascular system, the CNS, the intestine, etc.  Furthermore, antibiotics, analgesia, and anaesthetics should be available.   

However, it is always the escorting physician’s responsibility to make sure there are sufficient quantities of all the relevant medicine to last the duration of the transport in relation to the information he has been given.

It is common, but not obligatory, that the discharging hospital provides an air ambulance crew with drugs and fluids for the duration of the transport.   

Before departure, it is also the escorting physician’s responsibility to make sure that all the relevant equipment is available and that it works.

The air ambulance section

It is an advantage if the assistance organisation has a special air ambulance section dealing with all these transports.

In this way it is possible to build the required experience in planning, approving, and performing transports. At the same time, it ensures that focus is put on both quality and reasonable prices when dealing with the air ambulance companies.

The air ambulance section is a team of physicians, nurses, and experts in logistics.

Some of the big assistance organisations use “STEP”, which is a system for categorising air transport patients (for further details, please see Chapter 24).

If an air ambulance transport seems likely, the consulting physician should at an early stage contact a physician from the air ambulance section to discuss the case and propose a preliminary transport plan.

The air ambulance section cooperates with the assistance organisation’s transport department, thereby always focusing on whether a co-transport can be arranged.

The planning of air ambulance transports

Depending on the condition of the patient, and whether the air ambulance is initiated due to a medical or a logistical reason, different levels of medical information are required.

Medically reasoned air ambulance:

Basic information that should always be noted:

- STEP category (please see Chapter 24).

- The date of the last contact with the hospital.

- Any previous diseases of relevance.

- The course of the current disease, diagnostic measures performed, and the treatment given.

- The medical reason for choosing an air ambulance.

- Is the transport urgent? When can it be carried out at the latest?

- The deadline, if given.

- Ongoing medications.

-  Has the receiving hospital been informed and accepted the patient?

- Height (cm) and weight (kg).

Additional information depending on the patient’s disease and condition:

- Airways/respiration (breathing without any assistance? Oxygen needs? Intubated?  Etc.)

- Cardiovascular (BP, HR, arrhythmias? Need for pressure drugs?)

- Level of consciousness (Glasgow Coma Score).

- Degree of mobilisation.

- Infection.

- Bowel function.

- Relevant blood tests including haemoglobin.

- If obese, waist circumference and the largest diameter.

Ventilator patients. Following information is also required:

- FiO2

- Current blood gas analysis.   

- Intubated/tracheostomy.

- If tracheostomy, date of insertion, bleeding? Leakage?

- A recent chest x-ray. Findings?

- Ventilator settings.

- Tidal volume and minute volume.

- Peak Inspiratory Pressure over PEEP (PIP).

- PEEP

 

If obtaining all the information is difficult, FiO2, PIP, and PEEP are the most important parameters. 

When transporting intensive care patients and unstable patients, the consulting physician should obtain updated medical information from the treating physician no more than 12 hours before the air ambulance departs from home base.

Incubator transports are almost always carried out by an air ambulance. Regarding planning and transportation, please see Chapter 15.

Logistically reasoned air ambulance:

In such cases, only MEDIF informations is needed (the same as when transporting a patient on scheduled flights). Still please provide patient’s height and weight.

“Bed-to-bed” transport?

When an air ambulance transport is planned, it is important to decide whether it is required that the medical team from the air ambulance picks up the patient from the hospital and delivers him to the receiving hospital, a so-called “bed-to-bed” transport.  In some cases, when the patient is in a stable condition, it is appropriate that the ambulance team transport the patient between the hospital and aircraft.  When dealing with non-intensive care patients, this may be acceptable.

Thus, it is still a general rule that all air ambulance transportation of intensive care patients be carried out as “bed-to-bed” transports. This is the safest type of transport for the patient and, furthermore, it ensures that all the information and documentation follow the patient and can be handed over to the receiving hospital.

Wing-to-wing transport

A wing-to-wing transport is the term used for a transfer between two aircrafts or a helicopter and a plane. In intercontinental transport, this may simplify logistics and reduce costs. A “wing-to-wing” arrangement may also be necessary if a hospital is located by a very small airport or an airstrip, to bring the patient to a normal size airport (where the air ambulance jet may land). 

Contacting the receiving hospital

It is very important to contact the receiving hospital as early as possible to ensure that it is an appropriate hospital with suitable specialties and equipment, and that they have a free bed for the patient. At times, there may be lack of intensive care beds.

As long as the patient is not cleared for infectious diseases, the patient has to be kept in isolation; making arrangements for an isolation room are often difficult.

When transporting an intensive care patient, the following issues should always be arranged / clarified in regards to the receiving hospital:

- Does the patient belong to the given hospital?

- Name of the physician who has accepted to receive the patient?

- Make sure that this physician has the relevant competences of accepting the patient.

- Make sure that the physician responsible for the intensive care unit has also been informed.

- Inform about the patient’s course of disease and current condition including any suspicion of infection

  and if an isolation room is required.

- Agree on who is ordering the ground ambulance transfer (usually the air ambulance section).

- Agree on the exact delivery site and time (the emergency room, intensive care unit, etc.)

- Give the hospital a phone number to your alarm-centre, where they can call if any questions or

  problems occur.   

 

 

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