Disaster Emergencies

Air transportation for

critically ill patients

patients
Dr Peter Archer Director of Emergency Services Eastern Health
Medical Director Victoria
Disaster Retrieval Physician ARV Ambulance Victoria
National Critical Paediatric Emergency Physician Royal
Care & Trauma Children’s Hospital
Response Centre Field Emergency Medical Officer Program
Darwin Australia Clinical Lead AUSMAT
Use of aeromedical resources to
assist with the management of
critically ill patients in disasters
• Rapid deployment to remote locations
• Medical intelligence gathering, reconnaissance, and
mapping the geographical scale of the disaster
• Deployment of surgical and critical care resources
and teams to a disaster site
• Transport of critically ill, injured patients or those
likely to deteriorate
• high resource or special service requiring patients,
e.g. burns, spinal cord injuries, or amputations
Use of aeromedical resources to
assist with the management of
critically ill patients in disasters
• Transport of frail, unwell, elderly, pregnant
or special needs patients can prevent a
drain on local resources
• Transport of international patients will free
up resources to deal with the local
population
• Evacuation of high risk patients during or
prior to a disaster (including displaced
populations at risk of further harm)
INTERNATIONAL RESPONSE
National Critical Care and Trauma
Response Centre (NCCTRC)
• Vital element of Australian Government’s capacity
to respond to regional disasters
• clinical and academic leadership in disaster and
trauma care
• Local response capability
• International education, training and exercising
capacity
• Research into disaster response and the
improvement of first responders
• Links with health departments at national and state
level, academic institutions in Australia, the
Department of Foreign Affairs and Trade and with
regional and global partners such as the World
Health Organization (WHO)
NCCTRC
• Australian Medical Assistance Team (AUSMAT) has
trained more than 600 doctors, nurses and health
logisticians to a national standard as medical
disaster responders
• Trauma field hospital comprising an inpatient
facility, two operating tables and full resuscitation
and outpatient capability, to the standard of a WHO
EMT2 facility
• includes an infectious disease epidemic response
Rapid remote deployments
• In Australia, most of the population is based in coastal
centres
• Some emergencies occurring in remote or austere
environments
• Both civil and military aeromedical resources may be
required to assist
• This can then take the major load off overwhelmed
communities

• Strategy to distribute critically ill patients to areas that

may have more appropriate resources for care and
improved survival.
Fiji Cyclone Winston
 ASIAN TSUNAMI 2004
• 230,000 deceased
• 14 countries
• waves up to 30 metres
• Many teams Deployed
• Aeromedical reconnaissance
• Useful for planning
• Deployment
 Ausmat Tacloban
Airport deployment
Typhoon Haiyan
Tacloban
• Need for field surgical
hospital

• AUSMAT field surgical

hospital deployed 4 weeks
• 2734 presentations
• 238 theatre cases
• 541 occupied bed days
• 60 transfers
• 9 deaths
• 3 births
 CORE FUNCTION FUNCTIONAL AREA DR RN OTHER LOGS TEAM SIZE DEPLOY PERIOD
Team Leader 1
Leadership Clinical Leads 1 1 4
Logistics Lead 1
Triage 1 1 paramedic
Primary Care 1 1

AUSMAT
Emergency &
Surgical Care Emergency Care 2
Field 2
Hospital

Emergency Care [28 2 midwives /

TOTAL Maternal Care 4 20
stretchers] RN

Team Size:
1 paramedic
EMT TYPE 2

54

Deploy in under
Resuscitation 1 1 24 hours from
point of origin
1 radiographer
for a minimum
period of 21
days

Clinical admin / data 1

Stores / Pharmacy 1 pharmacist

Surgical
1 pathology
Perioperative Care [2 Orthopaedic 5 Periop 1 12
Operating Theatre (blood)
tables]
2 Anaesthetist
Obstetrician
Paeds [8 beds] 1 paediatrician 4
1 Rehab (Allied
General [18 beds] 4 1 18
Ward Care [30 beds] 1 physician Health)
HDU [4 beds] 4
 Ebola in West Africa
May 2015:

Country Cases Deaths

Guinea 3652 2429
Liberia 10666 4608
Sierra 12827 3912
Leone
Nigeria 20 8
Senegal 1 0
Mali 8
6

http://www.who.int/csr/disease/ebola/situation
-reports/en/

29
Aspen Medical Hastings Ebola
Treatment Unit Freetown Sierra
Leone
Black Saturday 2009 Victoria
Cyclone Tracy 1974 Darwin 25000
evacuated
Cyclone Yasi Evacuation Cairns
Base Hospital
• 356 patients, staff, relatives moved
• 16 special care unit babies (4
ventilated)
• 9 ventilated ICU patients
• 18 involuntary patients
• Coronary care patients
• Post partum mother with large PPH
• 21F with Ectopic pregnancy in ED
• 21 M Ventilated head injury post
assault
WA Health 2015
t
h
C
1
7 ICU consultant and staff on
flight

WA Health 2015
WA Health 2015
Bali 2002
59 patients evacuated to Royal
Darwin Hospital
1st plane arrivals 0215 to 0256
14 patients
5 patients - ISS 0 to 8
5 patients - ISS 9 to 15
4 patients - ISS 16 to 34
2nd plane arrivals 0710 to 0821
20 patients
3 patients - ISS 0 to 8
5 patients - ISS 9 to 15
12 patients - ISS 16 to 50
3rd and 4th plane arrivals 1230 to 1343
25 patients
8 patients - ISS 0 to 8
6 patients - ISS 9 to 15
11 patients - ISS 16 to 41
Kerang Train Crash Victoria 2010
Risk and cost
• period of assessment and stabilization at local
medical facilities or casualty clearing posts
• may be appropriate to prevent unnecessary
harm
• facilitate most appropriate patient selection
especially if there are large numbers of patients
involved
• Significant risks and difficulties found in the
aeromedical environment during transfer of
critically ill patient
• Patient preparation, packaging, and monitoring
• Appropriate high level Clinical care mitigates
against the risk
 Aeromedical Environment
• Stresses of flight may include
• Cramped space
• Hypoxia
• Barometric pressure changes
• Temperature variation
• Noise
• Vibration
• Gravitational forces
• Dehydration
• Fatigue
• Nausea
• Vertigo
Response

• Fixed Wing
• Rotary
Wing
• Road Car
 The Critical Care Patient
• Multi-system failure or Multi-system Trauma
• Minimal reserve
• High support requirements
• Difficult to package
• Longer retrieval times
• Monitor dependence
• Power supply issues
• Drug dependence
• Transport Ventilator Limitations
 Common Dilemmas
• Capabilities staff and availability
equipment dictates intervention
timing
• Does patient require intubation for
transfer?
• If so, intubate now, later or wait for
team to arrive to intubate patient?
• What IV access does the patient
require? CVC? Arterial line?
• Drug and Equipment Compatibility
• What will the retrieval team expect?
What will they want to take with
them?
• What if the patient’s clinical status
changes?
Preparation Key
• Safety
• Timeliness
• Stabilisation prior to
transfer
• Wherever possible
• Safest if interventions
occur on ground
• Triage to move sickest
patients first where
possible
Airway
ENSURE PATIENT AIRWAY SAFETY
1. Assess airway stability for all patients
2. Secure endotracheal tube
3. Record size and lip length
4. Oro-gastric tube placed
5. CXR to confirm position of endotracheal tube
Intubation for transfer
• This issue should be discussed with the ARV
medical coordinator before arrival of the retrieval
team.
• In general terms the patient should be intubated if:
• Aggressive, agitated or obtunded
• Clinical condition makes it likely that they will
deteriorate enroute e.g large ICH, complete cervical cord
injury
• Requiring non invasive ventilation in a hospital setting or
are fatiguing
• Threatened airway obstruction e.g burns, epiglottitis
When to Intubate
• Consider: risk of intubating now vs risk of waiting:

• Is the patient likely to aspirate? e.g altered conscious

state + vomiting
• Is the patient a risk to themselves? e.g agitated with
potential C spine injury
• Is the patient’s respiratory status or haemodynamics
deteriorating ?
• Do you have the skills to achieve intubation and manage
ingoing ventilation needs e.g. ventilating a sick asthmatic
When To Intubate (in an ideal world)

• Most senior medical and nursing staff available

• Ideally before it becomes an emergency,
• i.e semi-elective
• All drugs drawn up and contingency plans made and
communicated
• Sedation / induction
• Paralysis: Short/Long
• Difficult Intubation Drill
• Ongoing sedation and analgesia
• Appropriate staff and equipment available to look after
intubated patient until arrival of retrieval team
Breathing
ENSURE OPTIMISED OXYGENATION
1. Observe respiratory rate and character
2. Measure SpO2 and ETCO2
3. Administer oxygen
4. Correct delivery device
5. Check ABG’s if indicated/possible
6. Secure Intercostal catheters if present
Circulation
ENSURE IV ACCESS & MANAGEMENT
1. Insert two peripheral IV lines
2. Secure all lines – ensure injection ports are
accessible
3. Prepare drug infusions in 50 ml syringes.
4. For advice on infusion concentrations call ARV
5. Record all IV fluids
6. Transduce all arterial and central lines.
What Helps: Drugs
• All infusion drugs in 50ml syringe + minimum
volume extension tubing
• Sedation:
• 50mg morphine+ 50mg midazolam in 50ml N Saline
• Propofol 10mg/ml in 50ml syringe
• Neuromuscular Paralysis: the majority of intubated
patients when changing them over to ARV
equipment, +/- during the transfer
• We may request additional doses for the transfer
• Inotropes: Standard dilution, e.g 3mg in 50ml
Lines and Tubes
• IDC: all intubated patients
• NGT/OGT: all intubated patients
• Arterial line: if on inotropes/vasopressors or
hypertensive emergency. Ideally all intubated patients
• CVC: if time allows and appropriate clinician available.
• not necessary if hemodynamically stable & not
requiring inotrope support
• Peripheral access: 2 X wide bore easily accessible IVs
Other
1. Maintain body temperature
2. Consider indwelling catheter – maintain Fluid
Balance Chart
3. Empty drainage bags prior to transport
4. Administer antiemetic
5. Maintain spinal precautions if indicated
 Summary
• Aeromedical resources can assist with the management of
critically ill patients in disasters
• Rapid remote deployment
• Medical intelligence gathering ,reconnaissance, and
mapping
• Deployment of surgical, critical care and specialist resources
• Transport of critically ill, injured, frail,, pregnant or special
needs patients can prevent a drain on local resources
• Transport of international patients will free up resources to
deal with the local population
• Evacuation of high risk patients during or prior to a disaster
(including displaced populations at risk of further harm)
• Aeromedical environments are hazardous if unfamiliar with
risks
• Need a specialized approach and preparedness to ensure
safe transfer
• Need to ensure not ignoring appropriate ground or sea
resources where these exist
Acknowledgements
• Prof. Trevor Duke
• Dr Ian Norton
• Dr Allan McKay
• Dr Mark Little
• Mr Shaun Whitmore
• Assoc. Prof. Dan Martin
• Dr Emmaline Finn
• Assoc. Prof. Marcus Kennedy
• Assoc. Prof. Dianne Stephens